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E. B. TREAT, No. 75 7 BROADWAY. 

[Copyright, 1882.] 


To every one familiar with foreign Hospital Reports and Society Transactions, 
the value of illustrated articles is evident. While in this country there is no dearth 
of medical literature, it must be admitted that many of the rare and interesting cases, 
especially of a surgical or pathological nature, including methods of treatment, are 
imperfectly reported, or remain unrecorded, in consequence of the great expense attend- 
ing the production of satisfactoiy illustrations. It is the object of this volume to meet 
this defect. 

By means of photographs from life, chromo-lithographs of drawings from nature, 
and engravings of the highest artistic excellence, much valuable and instructive ma- 
terial from our most eminent professors and practitioners has been brought within 
the reach of the Profession, which has heretofore been withheld, or published at 
personal expense. 

The cases presented, in matter and illustrations, are original contributions to this 
work, and have been liberally paid for and copyrighted. 

George Henry Fox. 
Frederic R. Sturgis. 


This new candidate for professional favor is a model of its sort, containing 
elegantly illustrated articles of eminent professors. The general make-up is in 
the form and on the plan of the photographic illustrations of skin diseases, 
which proved itself so deservedly popular with the profession. 

New York Medical Record. 


The illustrations are well done, and are abundant even to profusion. The 
cases have been well chosen, and care has evidently been taken to have a fair 
variety in each number. We anticipate that this will be a popular and useful 
publication. London Lancet. 

Its contributors are men of national reputation, and the subjects are handled 
in a clear and instructive manner. The editors have spared no pains or expense 
in placing it at the head of medical literature, for it is a work much needed and 
full of practical information. 

New Orleans Medical and Surgical Journal. 

It is a publication of great merit. We have no fears of assuring its editors 
and co-operators of the certain success of their work. 

Medical Bulletin, Philadeljthia. 

The character of the illustrations, quality of paper, and clearness of the ty- 
pography bring it to the front rank as a first-class publication, and as such we 
cordially commend it. Therajieutic Gazette, Detroit. 

It should bo seen by doctors individually, in order that its qualities may be 
fully appreciated. The general practitioner will get from it such instruction as 
cannot be had elsewhere. Louisville Medical News. 

This new venture pre-eminently deserves general support — presenting excel- 
lent clinical accounts of interesting cases in practice, and also highly artistic 
pictorial representations of the cases themselves. The names of our professional 
brethren connected with the work is sufficient commendation for it. 

Canadian Journal of Medical Science, Toronto. 

The artotype illustrations are most excellent pieces of work and well colored 
by hand. We arc satisfied that there will be a large demand for this really val- 
uable work, because the subscriber will find himself in possession of a picture- 
gallery of the most unique cases in all branches of medicine and surgery. 

Canada Medical and Surgical Journal, Montreal. 

Such a work is valuable, not only in affording an enhanced facility of under- 
standing by the aid of good pictorial representations, but also in rescuing from 
obscurity and oblivion the record of valuable cases otherwise not published for 
want of sufficient intelligible illustration. 

Canadian Practitioner, Toronto. 


RESTORATION OF LIP, Five. Illustrations. (I 

By Alfred C. Post, M.D., LL.D., Emeritus Professor of Surgery and President of 
Medical Department, University of the City of New York. 

FIBROUS TUMOR OF FACE, ...... Three Illustrations. 17 

By Willard Parker, M.D., Professor of Clinical Surgery, College of Physicians 
and Surgeons, New York. 

By T. G. Thomas, M.D., Surgeon to the New York State Woman’s Hospital. 

By James L. Little, M.D., Prof. Clinical Surgery, University of the City of N. Y. 

By F. H. Bosworth, M.D., Surgeon to Out-door Department, Bellevue Hospital. 

By Sam’l Sexton, M.D., Surgeon to the New York Eye and Ear Infirmary. 


By T. R. Poolet, M.D., Assistant Surgeon N. Y. Ophthalmic and Aural Institute. 

OVARIAN PREGNANCY % ....... One Illustration. 33 

By Isaac E. Taylor, M.D., Emeritus Prof, of Obstetrics and Diseases of Women 
and Children, and Pres, of the Faculty of Bellevue Medical College, N. Y. 

FACIAL ATROPHY, ......... One Illustration. 35 

By E. C. Seguin, M.D., Professor of Diseases of the Nervous System, College of 
Physicians and Surgeons, New York. 


By Thomas T. Sabine, M.D., Professor of Anatomy, College of Physicians and Sur- 
geons, New York. 


By Robert Abbe, M.D., Surgeon to Out-Patient Department, N. Y. Hospital. 


PARAPLEGIA, Two Illustrations. 43 

By V. P. Gibney, M.D., House Surgeon to the Hospital for Ruptured and 
Crippled, New York. 


t 5 ] 


HIP DISEASE IN THE THIRD STAGE, History of three cases, . . Nine Illustrations. 45 

By A. B. Judson, M.D., Surgeon to Out-Patient Department, N. Y. Hospital. 

SKIN-GRAFTING (With Report of a Case), ..... Tico Illustrations. 53 
By G. A. Van Wagenent, M.D., late House Surgeon to Bellevue Hospital, N. Y. 

DUODENAL ULCER, ......... One Illustration. 57 

By Francis Wayland Campbell, M.A., M. D., L. R. C. P. Loxd., Prof. Theory 
and Practice of Medicine, University of Bishops College, Montreal. 

A NEW METHOD OF CLOSING URETHRAL FISTUL^E, . . Fourteen Illustrations. 59 

By Charles MoBurney, M.D., Visiting Surgeon to St. Luke’s and Bellevue Hos- 
pitals, Instructor in Surgery, College of Physicians and Surgeons, New York. 

GUMMOUS IRITIS (Two cases), Two Illustrations. 66 

By F. R. Sturgis, M.D., Formerly Prof. Venereal Diseases, Med. Dept. Univer- 
sity of City of N. Y., Visiting Surgeon to Charity Hospital. 


By George G. Wheelock, M.D., Attending Physician to St. Luke’s and the Nursery 
and Child's Hospitals, New York. 

PAPILLOMA OF PHARYNX, One Illustration. 69 

By John O. Roe, M.D., Rochester, N. Y., Fellow of the American Laryngological 

THERAPEUTIC USES OF RUBBER TUBING, .... Six Illustrations. 71 
By W. M. Chamberlain, M.D., Attending Physician to Charity Hospital, N. 1 . 

By M. Joslaii Roberts, M.D., New York. 

TWO LARGE TUMORS OF THE FEMALE BREAST, . . . Two Illustrations. 81 

By Wm. T. Bull, M.D., Surgeon to St. Luke’s and Chambers Street Hospital, N.\ . 

SARCOMA OF THE PHARYNX AND NECK, .... Three Illustrations. 85 
By L. A. Stimson, M.D., Professor of Surgical Pathology, University Medical 
College, New York. 

DOUBLE EQUINO VARUS, One Illustration. 87 

By Lewis A. Sayre, M.D., Professor of Orthopedic Surgery, Bellevue Hospital 
Medical College, New York. 

By E. P. Brewer, M.D., Pli. D., late Surgeon to Hartford Hospital, Conn. 


By Caul Seiler, M.D., Lecturer on Diseases of the Throat, l niversity Medical 
College of Philadelphia, Pa. 


By Wm. S. Ciieesman, M.D., Late House Physician to Bellevue Hospital, N. \. 


By A. L. Ranney, M.D., Adjunct Professor of Anatomy, University Medical 
College, N. Y. 


By J. E. Mears, M.D., Surgeon to St. Mary’s Hospital, Philadelphia. 


By Oliver P. Rex, M.D., Visiting Physician to Jefferson Medical College 
Hospital, Philadelphia. 

f 6 ] 


DENTAL DEVELOPMENT Three Illustrations. 

By Wji, Hailes, Jr., M.D., Professor of Histology and Pathological Anatomy, Albany 
Medical College. 


By Johnson Eliot, M.D., Emeritus Professor of Surgery, Medical Department of 
Georgetown College ; Surgeon to Providence Hospital, etc., Washington, D. C. 


By Randolph Winslow, M.D., Demonstrator of Anatomy in the University of Mary- 
land, and Professor of Surgery in the Woman’s Medical College of Baltimore. 

tions for restoration, with remarks on the operation for cleft palate Eight Illustrations. 

By James L. Little, M.D., Professor of Clinical and Operative Surgery in the New 
York Post-Graduate Medical School; Professor of Surgery in the Medical Department 
of the University of Vermont; Surgeon to St. Luke’s and St, Vincent’s Hospitals. 


By Charles Buckley, M.D., Member of the Rochester Pathological Society. 


By William Osler, M.D., M. R. C. P., Professor of the Institutes of Medicine, McGill 
University ; Pathologist to the General Hospital, Montreal, Canada. 


By J. H. Pooley, M.D., formerly Professor of Surgery in Starling Medical College; Pro- 

fessor of Medical Jurisprudence in Columbus Medical College. 


By Geo. J. Engelmann, M.D., Professor of Obstetrics in the Post Graduate School of 
the Missouri Medical College, St. Louis. 


By J. S. Wight, M.D., Professor of Operative and Clinical Surgery in Long Island Col- 
lege Hospital, Brooklyn, New York. 

ENCHONDROMA Two Illustrations. 

By W. W. Dawson, M.D., Professor of Surgery Medical College of Ohio; Surgeon to 
Hospital of the Good Samaritan, Cincinnati, Ohio. 


By W. A. Hammond, M.D., Surgeon General U. S. Army (retired list); Prof, of Dis- 
eases of the Mind and Nervous System in New York Post-Graduate School, etc. 


By Henry G. Piffard, M.D. . Surgeon to Charity Hospital, Blackwell’s Island, etc., N. Y. 


By Thomas R. Pooley, M.D., Permanent Member of the Medical Society of the State of 
New York. 


By Charles H. Knight, M.D., Assistant Surgeon, Manhattan Eye and Ear Hospital. 


By Frankltn Townsend, A.M., M.D., Prof, of Physiology, Albany Medical College, N.Y. 


By T. T. Sabine, M.D., Prof, of Anatomy, College of Physicians and Surgeons, N. Y. 

PLASTIC OPERATION ON THE FACE ... Four Illustrations. 

By Alfred C. Post, M.D., LL.D., Emeritus Professor of Clinical Surgery, and President 
of the Faculty in the Medical Department of the University of the City of New York. 

[ V ] 





















By Henry B. Sands, M.D., Professor of the Practice of Surgery in the College of Phy- 
sicians and Surgeons, New York City. 


By Charles F. Bevan, M.D., Professor of Anatomy and Genito-Urinarv Surgery, College 
of Physicians and Surgeons, Baltimore, Md. 


Two Illustrations. 

By George II. Fox, M. D., Physician to the New York Skin and Cancer Hospital. 


By J. H. Pooi.ey, M.D., Professor of Surgery in the Toledo Medical College. 

— Six Illustrations. 

By Charles T. Poore, M.D, Surgeon to St. Mary’s Free Hospital for Children, N. Y. 


By Edward L. Partridge, M.D., Professor of Obstetrics in the New York Post-Graduate 
Medical School ; Attending Physician to Nursery and Child’s Hospital. 


By J. S. Wight, M.D., Professor of Operative and Clinical Surgery in the Long Island 
College Hospital, New York. 


By George Thomas Jackson, M.D., Clinical Assistant to the Chair of Dermatology Col- 
lege Physicians and Surgeons, New York. 


Two Illustrations. 

By J. S. Wight, M.D., Professor of Operative and Clinical Surgery at the L. I. Col. Hosp. 


By Prof. J. L. Little, M.D., Professor of Clinical and Operative Surgery in the New 
York Post-Graduate School. 

A CASE OF HEREDITARY DEFORMITY. (Hands) Two Illustrations. 

By E. P. Williams, M.D., Physician to New York Dispensary. 


By Prof. Fessenden N. Otis, M.D., Clinical Professor of Venereal Diseases in College of 
Physicians and Surgeons, New York City. 


By Walter S. Ranney, M.D., Assistant to the Chair of the Practice of Medicine in 
Medical Department of the University of the City of New York. 

By L. Emmett IIolt, M.D., Late House Surgeon to Bellevue Hospital. 


By Charles Hermon Tiiomas, M.D., Surgeon to Philadelphia Hospital. 


By Herbert P. Lyttle, M.D., Associate Professor of Genito-Urinary and Venereal 
Diseases in the New York Post-Graduate Medical School. 
















( f Vtrse o(Pn>/\ I ( 'Past ) 





Emeritus Professor of Surgery in, and President of the Faculty of the Medical Department of the University of the City of 
New York; Visiting Surgeon to the Presbyterian Hospital, N. Y. City, dec., &c. 

Case. — Chas. Gardiner, Ireland, 65, shoemaker, married, admitted to hospital April 26th, 1880. 
Family and previous history good. 

Twenty-six years ago, a small wart appeared on upper lip, a little to right of median line. This 
remained twenty-two years without increasing in size and without pain. Four years ago, applications 
were made to it with the intention of destroying it, but they were not effectual. The wart ulcerated 
and increased in size, involving nearly the whole of the upper lip, and a portion of the right ala nasi ; 
but without giving rise to pain or constitutional disturbance. On March 31st, 1880, he went to a 
cancer doctress, who applied an escharotic paste which destroyed all the parts involved in the disease. 

On admission, there was found to be a deficiency of nearly the whole of the upper lip, the 
deficiency extending from the right cheek just without the angle of the mouth to a point about twelve 
mm. within the left commissure of the lips. The columna nasi had entirely disappeared, and there 
was a deep notch at the lower part of the right ala nasi about fifteen mm. in depth. The upper 
gums were entirely exposed to view. The patient was unable to keep his food between his teeth, and 
to retain the saliva within his mouth. (See plate I, fig. 1.) 

May 1st, 1880. The patient having been etherized with the usual precautions, I performed 
the following operation for the restoration of the lost features. (See fig. 3, 1 and 5.) I commenced 
by separating from the cheek the small remnant of the left extremity of the upper lip, by an 
incision extending through its whole breadth and thickness, leaving the flap thus separated, attached 
at the junction of the nose and cheek. The loose end of this flap and its anterior surface were 
excised, so as to leave raw surfaces for adhesion in the new position in which they were to be placed. 
A portion of this integument at the end of the nasal pyramid, and at the lower border of the septum 

1 9 1 


nasi were also excised, to produce raw surfaces corresponding with those of the labial flap. This flap 
was then drawn upward and to the right, and attached by sutures to the denuded surface of the nose, 
so as to form a new columna, the mucous membrane looking downward, and the denuded cutaneous 
surface looking upward. The position of the new columna was necessarily oblique, it being my 
intention to remove the obliquity by a subsequent operation, if it should be found necessary. 

The jagged edge of the parts at the junction of the right cheek with the lip was then 

excised so as to leave an even 
margin, and a flap was made 
from the left cheek, included 
between two incisions, of which 
the lower extended outward and 
a little downward from the angle 
of the mouth, and the upper, 
outward and a little upward from 
the junction of the ala nasi with 
the cheek, the flap thus formed 
being a little larger in all its 
dimensions than the left half of 
the space to be occupied by the 
new upper lip. From the outer 
extremity of this flap, two incis- 
ions were made in the arcs of 
circles -whose concavities looked 
toward the mouth, including 
between them a curved pedicle 
for the flap, about half the width 
of the flap itself. A correspond- 
ing flap with, a curved pedicle 
was cut from the right cheek, 
the flap being made sufficiently 
wide, not only to supply the 
right half of the upper lip, but 
to afford a patch to fill up the 
notch at the lower extremity of 
the right ala nasi. A horizon- 
tal incision was made twenty-two 
mm. in length, separating the portion of the flap designed for the reparation of the ala nasi from 
that which was intended for the completion of the upper lip. A thin strip was removed from the 
margin of the notch at the lower edge of the ala nasi, for the reception of the flap. The two flaps 
designed for the formation of the upper lip were then brought together in the median line, and 
joined by three pin sutures, and the remaining edges of the wound were united by numerous fine 

[ 10 3 


silken sutures. Before bringing the flaps together, as there was found to be some tension I cut 
across the mucous membranes of the pedicle of the right flap near its lower extremity, thinking 
that the mucous membrane of the flap itself would receive a sufficient vascular supply from the 
vessels of the submucous cellular tissue. A new Vermillion border was formed for each division of 
the lip, by drawing the mucous membrane forward, and attaching it by sutures to the external 

The patient bore the operation well, being kept in a state of anaesthesia by a very moderate use 
of ether. 

Fig. 3 exhibits the flaps which were designed to restore the columna nasi, the upper lip, and 
the defective portion of the right ala nasi. 

Fig. 4 shows the new columna attached by sutures to the apex of the nose. 

Fig. 5 exhibits the remaining flaps secured in place by sutures and the space behind the 
right flap, left to granulate. 

May 2nd. Patient is in a comfortable condition. He has taken milk and beef-tea during the 
night. The wound looks well, except that the vermillion border of the right flap has a somewhat 
dusky appearance. 

5th. One of the pins, and about half of the sutures were removed to-day. A lSrge part of the 
wound has united by first intention, but the vermillion border of the right flap is evidently gangrenous. 

May 10th. The remaining sutures were removed. 

16th. The sloughy margin of the right flap came away to-day. 

25th. Union is complete, except where the slough separated from the margin of the lip and at 
the posterior superior margin of the pedicle, where cicatrization is rapidly advancing. 

June 22nd. Every part of the sore is healed, except a minute portion about one cm. in length, 
and five mm. in breadth, at the posterior and superior margin of the pedicle, where the surface is 
covered with a thin scab on a level with the surrounding parts. The line of union of the right flap 
with the adjacent parts is at its proper level, except for a space of three cm. in length, extending out- 
ward from the angle of the mouth, when the line of union is depressed, and the adjacent surface 

The line of union of the left flap is level on its superior margin, and on the posterior side of 
its pedicle, but in other parts it is depressed, and the adjacent surface somewhat puckered. The 
vermillion border of the left flap is perfect throughout, and extends a little to the right of the median 
line. The free border of the right flap has no proper mucous covering, but the skin is inverted so as to 
form a fair substitute for a vermillion border, from the angle of the mouth about half way to the 
median line. Between the labial borders of the right and left flaps, there is a notch about two cm. 
long at the base, and extending upward to the height of one cm. above which the two sides of the lip 
are firmly but somewhat irregularly united. 

The flap which fills up the notch in the right ala of the nose is firmly united, but is abnormally 
thick. The new columna is perfectly united with the septum and the apex of the nose, and its 
obliquity is much less than might have been anticipated. (See plate I, fig. 2, see fig. 9, exhibiting the 
result of the first operation.) 

June 23rd. I performed the following supplementary operation. I first detached the left side 

L ii J 


of the posterior extremity of the newly formed columna to the extent of about three mm. I then 
excised a segment from the right edge of the columna, about three mm. in breadth in the middle, and 
tapering toward each extremity, and brought together by line sutures the sides of the chasm thus 
produced. I separated from the cheek the newly formed patch of the right ala nasi, by a deep 
incision, and dissected out a considerable portion of the subcutaneous adipose tissue, so as to diminish 
the thickness of the dap, and to reduce it to its proper level. The patch was secured in its place 

by line sutures. I then dissected 
out the thin cicatricial tissue on the 
right side of the middle of the lip, 
so as to leave the two divisions of 
the lip each with a straight parallel 
margin. The incisions were made 
in such a manner that the left or 
longer dap was bevelled at the ex- 
pense of its mucous surface, and 
the right or smaller dap was bev- 
elled at the expense of its cutaneous 
surface, so that when the daps were 
afterwards brought together, the 
left dap overlapped the right one, 
while the cutaneous surfaces of the 
two daps were on the same plane. 
This was done in accordance with 
a plan suggested by Dr. Packard of 
Philadelphia in a paper read before 
the New York Academy of Med- 
icine. The two daps were both 
detached from the bridles which 
bound them to the upper jaw and 
to the buccal mucous membrane. 
I then made an incision on each side 
on a line corresponding with the 
upper margin of the lip, extending 
into the cheek to the distance of 
about four cm., and the same line 
of incision was then curved downward behind the angle of the mouth, and forward along the 
lower lip to the extent of three cm., the daps of the lower lip being about twelve mm. in 
breadth. The two daps of the upper lip were then brought together near the median line, and 
were secured by two pins and a number of due sutures. A small triangular surface on the right 
cheek, about twenty-five mm. in length was left to granulate. This space was lightly filled with 
picked lint moistened with a solution or carbolic acid, one part to forty, and the surface was 

[ 12 ] 


covered with lint moistened with collodion. The patient bore the operation well, and was in a good 
condition at its close. 

July 3d. There is a considerable separation of the flaps in the median line. There is 
sloughing of a considerable portion of right side of lip. Surface thoroughly washed with carbolic lotion. 

20th. Since the separation of the sloughs, the flaps have been supported by strips of adhesive 
plaster, and the intermediate space has been tilled by granulation. 

25th. There is firm union between the flaps by a narrow band with a notch below, and a small 
hole above. There is also a slight notch at the lower margin of the right ala nasi. 

Sept. 9th. I performed another operation as follows. I made an incision along the base of the 
lower jaw, commencing at the median line, and extending to the right to a point about three cm. 
oeyond a perpendicular line falling from the right angle of the mouth. The incision was then curved 
upward and backward to the horizontal level of the angle of the mouth, and thence upward and 
forward to the junction of the upper lip with the ala nasi, and thence forward along the upper margin 
of the lip into the vacant space which was left by the sloughing which followed the previous opera 
tion. This incision was extended deeply into the subcutaneous tissue along the base of the jaw, and 
when it passed through the cheek, it was extended through the mucous membrane into the buccal 
cavity. At the inner extremity of the large flaps included within the limits which have been described, 
a portion of the free margin of the right side of the lip was detached by an oblique incision from this 
isthmus, leaving a flap about twelve mm. in length, and five mm. in breadth at its right extremity 
and tapering to nothing at the left. A corresponding surface was prepared for the reception of this 
oblique flap, by dividing the left portion of the lip to a similar extent. The cicatricial tissue between 
the right and left portions of the lip was then dissected out. The right division of the lip, with the 
large curved flap to which it was attached, was then drawn to the median line, and attached by 
two pin sutures and a number of fine silk sutures, in such a position that the small oblique flap con- 
nected with the right segment of the lip overlapped the denuded portion of margin of the left seg- 
ment, and was placed in accurate coaptation with it. In this way, the whole of the face margin of the 
lip was made continuous, without any appearance of a notch. After securing the lip in its place, the 
whole circumference of the flap was closely attached by sutures to the surrounding parts, without undue 
tension at any point. All the parts were then washed with carbolic acid lotion, one part to forty. 

15th. Pins and sutures removed. Union throughout, except at two points, one a cm. from the 
columna, and a second smaller surface a little further to the right. The parts were supported by strips 
of adhesive plaster. The result of this operation was entirely successful, but when the parts were 
healed, there was a marked deficiency of the vermillion border of the right side of the upper lip, and 
a superfluity of the corresponding border of the lower lip. 

On the 14th of October I operated, with the hope of remedying this condition. 

A point was selected about seventeen mm. above the right angle of the mouth, and another 
point at the junction of the skin with the vermillion border of the lower lip, two cm. to the left of 
the right angle of the mouth. At each of these points a small pin was inserted through the skin, while a 
third point was selected in the cheek six mm. below a horizontal line extending back from the second 
point indicated and four cm. to the right of the angle of the mouth, and a third pin was inserted 
at that point. These pins were designed to mark the outlines of a triangular flap, whose base 

[ 13 ] 


embraced the angle of the mouth, and whose apex corresponded with the point indicated by the third 
pin inserted into the cheek. Introducing the index linger of my ieft hand into the buccal cavity as a 
guide, I inserted the point of a Beer’s cataract knife, at the point indicated by the first pin, into the 
cavity of the month, and made an incision to the point indicated by the third pin. I made another 
incision in the same manner from the third to the second pin, and thus separated the triangular flap 
from all its connections except around the angle of the mouth. From the point indicated by the 

first pin, I made another incision 
vertically upward to an extent 
corresponding with the space be- 
tween the first and third pins. 
This incision was earned to the 
periosteum, and from the tension 
of the parts involved, the edges 
receded so as to make a triangular 
chasm, adapted to the reception of 
the triangular flap. The flap was 
then turned edgewise until its apex 
was received into the apex of the 
triangular chasm, where it was 
firmly secured by a pin suture. 
The flap thus transplanted carried 
with it a considerable portion of 
the vermillion border of the lower 
lip, so as to bring it into line with 
the vermillion border of the upper 
lip. The flap was then secured by 
fine sutures to the edges of the 
triangular chasm, the outer line of 
the triangle being nearly vertical, 
while the inner line passed obliquely 
inward and downward toward the 
columna nasi. The edges of the 
chasm, from which the flap had 
been cut, were brought together 
with one pin suture and a num- 
ber of fine silk sutures, the line of union extending from the outer side of the base of the flap 
in a direction downward and outward. When the wounds were all closed, it was found that the 
superfluity of the lower lip was entirely overcome, while there was ample material provided for the 
reconstruction of the upper lip. The flap which had been transplanted appeared more prominent 
than the surrounding parts, making the right side of the lip thicker than the left, which was the 
reverse of its previous condition. 

L n J 


The pins were removed on the 15th and 16th, and the sutures on the 23d. The wound healed 
perfectly, leaving the right angle of the mouth elevated above its proper level to the extent of fifteen 
mm. The right cheek and the corresponding angle of the mouth were adherent to the maxillary bone. 

On the 11th of November I endeavored to overcome these defects by the following operations. 
I divided the adhesions connecting the soft parts with the bone, arid then cut a triangular flap with its 
apex above, and its base including the angle of the mouth, carrying the incisions into the buccal cavity, 
and drawing down the commissure of the lips until the angle of the flaps had descended about 
twelve mm. below the point from which it had been detached. This flap was fixed by sutures in its 
new position, and the sides of the space from which it had been taken were fixed in the same way. 
An incision was made above the portion of the vermillion border which had been raised from the 
lower lip, and a raw surface was made rrpon the corresponding edge of the upper lip to receive the 
flap thus raised, and this detached portion of vermillion boder was then drawn across towards the 
median line, and secured by sutures in its new position. The position of the angle of the mouth was 
improved, but it was still above its proper level. To assist in bringing it down I cut another triau 
gular flap below the angle of the mouth, its base including the commissure of the lips, and its apex 
extending toward the base of the lower jaw. Below the angle from which the apex had been cut, I 
made a straight incision downward to the extent of fifteen mm. and separated the sides of this incis- 
ions from each other, so as to form a new triangular flap. I then passed a loop of thread through the 
flap a little above its apex, and made traction so as to draw the apex of the flap down to the apex 
of the new triangular chasm. While this traction was made the flap was secured in its place by 
sutures, and the angle of the mouth was brought nearer to its proper position, but it still remained 
a little higher than that of the opposite side. 

The sutures were removed on the 15th, and the wounds healed by first intention. 

December 9tli. The right angle of the mouth being considerably nearer to the median line 
than the left, I performed another operation for the purpose of extending the commissure outward and 
backward. To accomplish this object, I made an incision through the upper lip at the junction of the 
vermilion border with the skin, extending through the whole thickness of the lip into the buccal 
cavity, beginning about one cm. from the angle of the mouth, and carried around the angle along the 
lower lip, terminating at a distance of eighteen mm. from the commissure of the lips. I then made 
another incision commencing three mm. below the augle of the mouth, and extending fifteen mm. 
horizontally outward and backward through the whole thickness of the cheek, the anterior and internal 
extremity of this incision corresponding with the wound by which the vermilion border was detached 
from the cheek. A blunt hook was then introduced through a portion of the vermilion border 
detached from the lower lip, seven mm. on the inner side of what had previously constituted the angle 
of the mouth, and was drawn through the horizontal incision in the cheek, and the corresponding por- 
tion of the detached vermilion border w r as fixed in that position by a bead suture extending through 
the cheek eighteen mm. beyond the outer extremity of the wound. In this manner, the angle of the 
mouth was extended outward, and provided with vermilion border, mainly at the expense of the lower 
lip. The flap thus transplanted was secured in position by fine silk sutures. 

23d. I made another effort to bring down the upper lip to its proper level. I made a horizontal 
incision immediately below the nose, extending on each side to a point vertically above the commissure 

[ 15 1 


of the lips, and thence continued on each side downward and outward to the extent of six cm. beyond 
the angles of the mouth. These incisions were carried through into the buccal cavity, and the lip was 
brought down into its normal position. I then made an oblique incision through the lip, commencing 
at its upper part on the left side of the median line, and extending down to the vermilion border one 
cm. to the right of the median line, and the parts were then united by sutures, so that the rela- 
tively superfluous vermilion border of the left side overlapped the margin of the right side, a raw 
surface having been made for its reception. An attempt was then made to close the chasm made 
by the depression of the right side of the lip, by dissecting a flap from the upper part of the cheek, 
with a pedicle curved downward and outward to a point twelve mm. in front of the lobe of the 
ear. But when the flap was dissected from the subjacent parts, it was found that it could not be 
brought over to the internal limit of the chasm which it was designed to fill. In order to bring the 
flap into place, it was necessary to perform the hazardous experiment of dissecting the pedicle down- 
ward and inward to the base of the jaw, leaving the narrowest portion in front of the lobe of the 
ear only twelve mm. in breadth. The flap was then readily brought into place and secured by sutures, 
leaving a large chasm around the posterior circumference of the transplanted flap. The portion of the 
wound uncovered by integument was dressed with lint moistened with collodion. The surface of the 
flap was covered with lint smeared with salicylic ointment. 27th. The flap, which was at first pale, 
has assumed a brighter color. There is some oedcmatous swelling, with a burning sensation. The 
surface was washed with a carbolic acid lotion, one part to forty, and again dressed with salicylic oint- 
ment. 28th. A slight blush of erysipelas has appeared in the integument of the eyelids of the right 
side, and the flap has begun to assume a livid color. Ordered sulph. quinine, gr. viij., and tinct. ferri 
chloridi, min. x., to be given, and the inflamed integument to be penciled with tinct. iodini. 29th. 
The extremity of the Hap, to the extent of five cm. has evidently lost its vitality. The erysipelas is 
spreading over the forehead, and has extended to the occiput. Jan. 5th, 1SS1. The space left by the 
separation of the slough is filling up with granulations. Feb. lltli. The contraction of the granula- 
tions, and the process of cicatrization, have gone on, until the chasm left by the separation of the 
sloughs has become nearly filled. March 4th. The wounds are substantially healed, and the 
right angle of the mouth has been drawn up nearly to the same position as before the last 

By my advice, the patient left the hospital, and went home to recruit his general health. I 
iiope at some future time to make an effort to improve the position of the right oral commissure. 
The result of the first operation performed on this patient was very satisfactory, although it was 
far from restoring the perfect symmetry of the face. The subsequent operations contributed much less 
to the improvement of the patient’s appearance than it was hoped that they would. The whole 
result has been the reconstruction of an upper lip which had been almost completely destroyed, the 
partial reparation of the notch in the right ala nasi, and the complete restoration of the columna nasi. 
The left side of the lip is nearly perfect, but the right side is drawn up above its proper level, and the 
mouth cannot be perfectly closed. 

Note. This case was reported at the meeting of the American Medical Association held at Richmond, Va., May 
4th, 1881, but lias not been given to the public until the present time. 

[ 1 « ] 



(Case of Prof. Willard Parker.) 



Professor of Clinical Surgery , College of Physicians and Surgeons , N. Y. ; Consulting Surgeon to the New York, Bellevue, 

St. Luke's, Mt. Sinai and Roosevelt Hospitals, &c., &c. 

The accompanying plate II. (Fig. 6, 7, 8) represents the following : 

Case. In February, 1863, I. I., aged 60, a mechanic from Cortlandt, Westchester Co., N. Y., 
called at my office to consult me in relation to a tumor on the face. lie was of industrious and regular 
habits, of a healthy family, and gave the following history. 

Thirty years ago he first observed a swelling, the size of a pea, situated a little in front of the 
ramus of the jaw, below the zygoma. During the subsequent twenty years it grew slowly, attaining 
the size of a hen’s egg — there was nc pain or tenderness. Within the past ten years the growth has 
been more rapid, it having more than doubled in size during the past five years. 

It now measures at its base eighteen inches ; at its greatest circumference, twenty-two inches. It 
is attached from the malar bone above, to a point upon the neck two inches below the thyroid cartilage, 
and, in front, from the angle of the month to two inches below the thyroid cartilage. 

It projects from the face some six inches, its vertical diameter being about eight. It is freely 
movable, and its surface is covered with nodules varying in size. The whiskers cover its posterior 

He was admitted into St. Luke’s Hospital, where I was consulting surgeon, and a consultation 
was called. The decision being to remove the mass, the patient readily assented and the operation 
was performed on February 27th. 

An incision was made around the base of the tumor, which was readily dissected out from its 
attachments. The muscles of the neck and jaw were not interfered with, and no large vessels were 
encountered, though there was tolerably profuse hemorrhage from a number of smaller vessels. Some 
difficulty was experienced in bringing together the edges of the wound. The wound healed readily, 
largely by first intention, the patient leaving the hospital at the end of a month with complete cicatri- 
zation and but little deformity. 

[ 17 1 


In consulting my record books I find the history of two other cases which will be of interest, I 
think, to the readers of this journal. 

I insert them here briefly. 

Case. — A French gardener, aged 51, consulted me some years ago on account of a large tumor on 
left side of face, extending from the zygoma to a point about two inches below the angle of the jaw. 
He had discovered some twenty-one years previously a small movable tumor, which was without pain or 
tenderness. For fifteen years its growth was slow, giving no special annoyance. For some five years 
subsequently its growth was more rapid, and within the previous two years it had become vascular, and 
at times, painful. Apprehending that the character of the growth was changing, I advised its speedy 
removal. My advice was followed, and he came to the city for operation. Xo special difficulty attended 
the removal of the tumor, the hemorrhage, though considerable, being readily controlled. The patient 
made a good recovery, but the tumor returned within about a year’s time, the patient dying of malignant 
growth in the cicatrix. The tumor weighed two and one-half pounds, and had assumed a malignant 
character at the time of removal. 

Case. — An unmarried woman, aged 40, of healthy family, presented herself with a tumor on 
right side of face, of some nineteen years’ duration. Its history was almost identical with the two pre- 
viously given. General health of patient good. Tumor removed by operation, recovery rapid and 
satisfactory. Xo subsequent history of return of disease. 

Although the histology of Fibromata is understood by the medical profession, their cause has not as 
yet been definitely made out. It develops in all tissues; beginning as a very small tumor, its growth is 
slow, it is local in its character, and unaccompanied by pain, heat, or tenderness; the deformity 
when in an exposed part, being the only cause of complaint. 

The diagnosis of Fibroma is generally easy, the only other growths liable to be confounded with 
it being lipoma, chondroma, cystic and adenoid growths. The malignant tumors differ from it in 
that they are generally painful, of rapid development, and occur in an unhealthy system. In fibroid 
growths the prognosis is good as regards a return of the disease, but it may develop in organs where 
surgical interference would jeopardize life, or when it so embarrasses vital action as to cause death. 

The only treatment is removal of the growth, and the earlier, the safer. The reasons for early 
removal are : 

1. When the growth is small the operation is less dangerous. 

2. When located near important organs, or internally, its relations may be such as to render 
an operation difficult or even impossible. 

Fibrous tumors, like all other abnormal developments, have a tendency to change of character, 
and may become malignant. Malignancy is, as a rule, never a first condition, but is in the beginning 
an outgrowth of some previous abnormal condition or growth. 

To sum up briefly, cancer is traumatic , or has its origin in a previous lesion. 

[ 13 1 




Surgeon to N. Y. State Woman's Hospital. 

Mrs. A., a native of France, forty years of age, a widow, who had borne one child, entered my 
service in the Woman’s Hospital, and gave the following history. For the past sixteen years she had 
suffered from what a large number of physicians who had examined her had uniformly pronounced to 
be a fibrous tumor of the uterus. At the commencement of that period she had spent eight months 
in the hospitals of Paris, and had since consulted many physicians, but without obtaining any 
relief whatsoever. The three distinguishing features of her case were these: first, since its development 
the tumor had neither increased nor diminished in size ; second, it was at all times exquisitely sensitive 
to pressure, and especially so during menstruation ; and, third, pain occurred in it during every 
menstrual act, so severe that nothing gave her relief except a free resort to opium. Her suffering dur- 
ing menstruation I have never seen surpassed, and she had become so demoralized by it that her object 
in entering the hospital was to have the growth removed at all hazards. 

Upon examining her I found the pelvis filled by a tumor about as large as the head of a child a 
year old, which, as I have already said, was very sensitive to pressure. It was apparently solid, only 
slightly movable, and by conjoined manipulation appeared to be attached directly to the uterus. I saw 
no reason to differ from the diagnosis which had been heretofore made in the case, although I was 
very much puzzled by the existence of the three peculiar features to which I have already referred. 

I dissuaded the patient from operation, but she was so much distressed at this that I got my 
colleagues, Dr. T. A. Emmet and Dr. J. B. Hunter to see her with me in consultation ; she indulging 
the hope that they might differ with me in this regard, and declaring that so great were her sufferings 
that she would infinitely prefer a resort to surgical interference, however great the dangers might be, 
than to remain exposed to them. Drs. Emmet and Hunter agreed both in the diagnosis and in the 
propriety of refusing operation. The patient then left the institution, and I did not see her for five or 
six months, when she returned again urgently demanding operation. I kept her in my service for some 
time, and then, with regret, again dismissed her without having afforded her any permanent relief. 

Two months after this she saw me at my office, and so fully described her sufferings, and 

[ 19 J 


so earnestly pleaded for relief that I again admitted her to the hospital, promising to remove the 
ovaries by Battey's method, in the hope of, in this way, relieving her of at least the greater portion of 
her troubles. For this operation, she entered my service during the year 1SS1. 

I cut down through the abdominal walls, and reached a tumor which looked exactly like a 
fibroid. I put my lingers upon it, and was surprised to find an obscure and yet distinct sense of fluctu- 
ation, which had not been recognized through the abdominal walls. Instead, therefore, of going on 
with the intended operation, I introduced a canula and trocar into the fluctuating tumor, and on 
withdrawing it there immediately escaped a pint or a pint and a half of menstrual fluid. It had all the 
characteristics of that fluid, and there could be no mistake with regard to its nature. 1 was very much 
puzzled by this, for the woman had been carefully examined, she had menstruated regularly, the uterus 
had been repeatedly measured, and was found to be two inches and a half in length. Taking hold of the 
tumor with two strong tenacula and drawing it up into the abdominal wound, I passed my hand down 
and discovered its relations, when at once it flashed across my mind that this was a uterus bicornial ; 
that the canal in the left horn was free, and allowed the escape of the menstrual fluid from that side, 
while the canal in the right horn was not open throughout its entire length, and consequently obstructed 
the menstrual discharge from that side. 

The original condition of the parts was probably that repi’esented in Fig. 9 or Fig. 10, one 
cervix being pervious, and the other impervious, if the uterus were originally bicornate as represented 
in Fig. 9, or else no cervix existing if the organ were originally uuicornate as represented in Fig. 10. 

Fig. 9. — Bicorn Uterus. Fig. 10. —Unicorn Uterus. 

Under such circumstances, one uterus, or rather one horn, discharges menstrual blood; in the 
other, that fluid, secreted by the endometrium, accummulates and creates a tumor presenting many of 
the features of a fibroid. 

When this thought suggested itself I was able to account for all the peculiarities of the 
case: First, the fact that the tumor had the appearances of a fibroid, and gave such agonizing pain at each 
menstrual period ; second, the fact that the tumor remained at about the same size, not growing larger, 
as a fibroid would do, although it was not at all impossible for a tumor of this character to have become 
larger by gradual distension ; and, lastly, the fact that the patient had comparative immunity from pain 
between the menstrual periods. I now found myself in an unfortunate dilemma, for had I proceeded 
to remove the ovaries, blood would have escaped from the wound into the abdominal cavity, and would 
very likely have set up fatal peritonitis or septicaemia. Hence, I adopted a course which struck 
me, as under the circumstances, the only one which would meet the emergency. 

[ 20 J 


The following diagram, Fig. 11, will show the condition of affairs at this stage of the operation. 

I caught hold of the uterus 
on one side, and Dr. Ward on the 
other, each with a strong tenaculum, 
and dragged it firmly Tip into the 
abdominal wound, and passed two 
strong knitting-needles through the 
tumor and laid them on the ab- 
dominal walls above and below the 
point of puncture. 1 then passed 
two sutures deep down, and fastened 
the tumor in the abdominal wound, 
and left a tube in for drainage and 
irrigation. I remarked to the spec- 
tators present, that the woman would 
almost surely suffer from septicaemia, 
and this prediction was fully verified ; 
but by having the cavity constantly 
irrigated with carbolized water, and 
controlling the temperature by Kib- 
bee’s method of affusion, she re- 
covered. A day-to-day history would 
accomplish nothing in increasing the 
interest of the case, hence, I spare the reader a recapitulation of it. It suffices to say that the 
uterine cavity was thoroughly washed out with carbolized water every four or five hours ; the tem- 
perature, which rose to 106°, kept in the neighborhood of 100° by affusion ; and quinine and opium 
used freely ; and the patient treated in all respects as she would have been after ovariotomy. 

At the next period, menstrual blood escaped simultaneously from the vagina and the abdom- 
inal wound, the drainage tube not having been removed from the latter. Never have I known more 
complete relief ensue from any operation than from this one. The patient constantly expressed her- 
self as entirely relieved, and is so well satisfied with her present condition that she is entirely 
unwilling to consider a procedure to which I shall soon allude for improving it. 

For her, however, to continue in her present state of comfort, it is evidently essential that 
the abdominal opening shall be kept free until the menopause. To accomplish this, as soon as the 
menstrual period was over, I had constructed a solid glass rod represented in actual size by Fig. 12. 


This, the patient wears constantly, except at menstrual periods, keeping it in position by a 
girdle which presses upon its head, and at the same time sustains the parts about the incision. 

She has now left the hospital, but reports to me occasionally, and has been instructed how to 

allow the free escape of menstrual blood 
by the genu-pectoral position, and how 
to wash out the cavity with carbolized 
water, in case of any septic symptoms 
attending upon or following menstruation. 
This last maneuvre she has frequently 
practiced, and perfectly understands. Fig. 
13, although a rough diagram, represents 
very accurately, I think, the present state 
of affairs. 

When this operation was adopted, 
I felt that it had helped my patient 
and myself out of a very difficult dilem- 
ma, but at the present time I do not 
feel at all satisfied with the statu s rerum. 
Should the patient not become pregnant, 
it is highly probable that all will go well 
with her until the menopause, but should 
pregnancy occur in the left horn, the right 
and a fatal issue would occur. 

At the moment of operation, and since that time, the propriety of penetrating the impervious 
cervical canal of the right horn, keeping it permanently open, closing the upper opening, dropping 
this horn into the pelvic cavity, and then closing the abdominal wound, has been carefully considered. 

As is so often the fact, under similar circumstances, the advisability of this course will very 
likely be immediately determined upon by many who have not had an opportunity of observing the 
ease. To those who have watched it with keen anxiety, through its various phases, much more 
difficulty will attend the decision. The patient is past forty; should conception occur the propriety of 
checking utero-gestation would be quite evident ; the patient, who has gone through with a great deal 
of suffering, strenuously objects to interference with a condition which is perfectly satisfactory to her 
and the dangers attendant upon the steps referred to would be very considerable. 

So many years have elapsed since pregnancy occurred with her, that 1 think it highly improb- 
able that it will now take place after the fortieth year. Should it do so, I should feel myself called 
upon under present circumstances to put a stop to its progress. This, however, I should feel justi- 
fied in doing only once ; having once resorted to it as a therapeutic resource, 1 should feel it my duty 
to urge upon her a resort to those further surgical steps which I have mentioned. 

[ 22 ] 


A. B. Abdominal walls. C. Glass plug. D. Uterine body fastened to the abdo- 
minal wulls. E. Uterus with pervious cervical canal. i\ Vagina. 

will assuredly be torn away from its abdominal moouings, 




( f 'ase of Pro / '• / L.Liff f A 1 



Professor of the Principles and Practice of Surgery, University of Vermont; Professor of Clinical Surgery , 
University of New York ; Surgeon to St. Luke's Hospital , New York City , c fee., &c. 

Plate III. illustrates this somewhat rare form of injury. The separation is complete except at 
the inner and external surface, where a small piece of the shaft was chipped off and remained attached to 
the epiphysis. This small piece was lost before the sketch was made by the artist, Mr. George C. Wright. 

The history of the case is as follows : On April 18th, 1865, a boy, aged eleven, while hanging 

on the back of a wagon, stealing a ride, had his right leg caught between the spokes of the wheel while 
in motion. The result of this sudden and forcible twisting of the leg was to cause a diastasis of the 
lower epiphysis, and the forcing of the lower extremity of the shaft through the soft parts 
on the upper and outer part of the popliteal space, the upper fragment completely overlapping the 
lower. The protruding part of the shaft was cleanly stripped of its periosteum for a space of about 
three inches. The hemorrhage was quite free, but no ligatures were necessary. The fragments were 
readjusted by strong extension of the limb, and flexion of the leg upon the thigh while patient was 
under the influence of ether. A dull cartilaginous crepitus could be felt when the fragments were 
moved upon each other. The wound did not appear to communicate with the knee joint. After 
reduction, the limb was placed on a double inclined plane. The following day, the upper fragment was 
found to be displaced. The patient was again placed under an anaesthetic, and it w-as then found that 
the fragments could be kept in place only by extreme flexion of the leg. This position was maintained 
by binding the leg to the thigh by means of strips of adhesive plaster. This apparently constrained posi- 
tion was not uncomfortable to the patient. On the thirteenth day alarming secondary hemorrhage took 
place while dressing the wound. This was controlled by a tourniquet, and as soon as the patient rallied 
from the effects of the loss of blood, amputation of the thigh at its lower third was performed. The 
boy made a good recovery. The hemorrhage was found to have come from an injury to the anterior 
tibial artery near its origin. The plate shows the situation of the wound. 

Dr. Hamilton, in his work on Fractures and Dislocations, reports three additional cases of this 
form of injury. In one case, an abscess formed and amputation became necessary ; in another, 

t 23 1 


the boy recovered with a straight leg, but with complete anchylosis of the knee joint and short- 
ening of the limb three-quarters of an inch. 

The lower epiphysis of the femur does not become united to the shaft until the twentieth year. 
So that at any period under twenty it is possible that this form of injury may occur. In several cases 
that have been reported, the accident happened in the same way, the leg being caught in the spokes of 
a wheel while in motion. This, like the separation of epiphyses of other bones, rarely, if ever 
takes place without a chipping off of a small portion of the shaft. In some cases there is a partial 
separation of the epiphysis with a fracture of the adjacent portion of the shaft, leaving a large 
portion of the latter attached to the condyle. In the museum of St. George's Hospital, London, 
there are two specimens of this last variety, in one of which the lower fragment is in two pieces.* 

In cases where the injury is not compound, displacement of the upper fragment, downwards and 
backwards, may be so great that the nerves and vessels may be stretched over its edges. In one case, 
under Dr. Me Burney’s care, at St. Luke's Hospital, the internal popliteal nerve was so stretched, the 
pain so intense, and the deformity so great that amputation was resorted to. The case was of two or 
three months’ standing, and strong bony union had taken place. The patient died of tetanus. 

In this case, and in my own, as well as in the case reported by Dr. Hamilton, the periosteum 
was completely stripped from the end of the shaft. Jonathan Hutchinson says: ‘‘This is, I believe, 

invariable in cases of detachment of an epiphysis with displacement.” The periosteum is always 
left its a sleeve in connection with the epiphysis and the shaft is denuded. f In Dr. McBurney’s 
case, although it was not compound, and union had taken place before amputation, yet the lower 
end of the shaft was found to be bare of periosteum. The vitality of the bone was not interfered 
with by this loss. 

In this case, as well as in two cases described by Hutchinson, the epiphysis was drawn into 
the flexed position by the action of the gastrocnemius muscle. This condition seems to be difficult of 
rectification, and coaptation of the fragments can only be maintained by placing the limb in the posi- 
tion of extreme flexion. 

The results of this injury when compound are unfavorable. Secondary amputation has been 
frequently resorted to in consequence of the profuse suppuration and difficulty of keeping the fragment 
in position. 

* Surgical Treatment of the Diseases of Infancy and Childhood. By T. Holmes, 18G9. Page 25‘J. 
t Illustrations of Clinical Surgery. Vol. II. Page I. 

[ 24 ] 



Lecturer on Diseases of the Throat in the Bellevue Ilosgntal Medical College . 

Lying immediately below the cartilage of the nasal septum, and parallel with its lower border, 
is a small oblong plate of cartilage not usually mentioned in the text-books of anatomy. It lies im- 
mediately beneath the integument of the columna, and can be easily grasped between the thumb and 
forefinger. It seems designed to give firmness and shape to the columna, and also probably aids in 
supporting the tip of the nose. 

Within the past year, two cases of lateral displacement of this cartilage have come under my 
care, which seem to possess an interest from being somewhat unique and also from the simplicity and 
success with which the deformity was rectified. 

The first case was that of a gentleman from Illinois who consulted me in March last, reporting 
that two years before he had noticed that something was growing in his right nostril. He had paid little 
attention to the matter at the time, but the condition had progressively grown worse until, at the time 
he came to the city, the deformity had increased to such an extent that there was not only a consider- 
able degree of closure of the nostril, but the nose presented such a noticeable loss of symmetry as to 
become a source of no little mental distress. In fact, the matter annoyed him so much that he came to 
New York with the sole purpose of seeking relief by some surgical operation. When I saw him the 
nose presented much the appearance illustrated in the accompanying sketch. The general facial 
expression, however, was even more noticeable than is suggested by the cut ; it was very peculiar, and 
indeed almost sinister, and I was not surprised at his anxiety for relief, especially as he said the 
deformity seemed to be increasing. The case w T as unique to me, and I was at first somewhat puzzled 
to determine its nature. On examination, however, I found that the columnar cartilage was displaced 
laterally, and at the same time tilted upward in such a manner that its posterior angle protruded into 
the nostril in an upward direction. It was easily grasped between the finger and thumb, and its outlines 
sufficiently showed that there was no deformity of the cartilage, or new growth. I urthermore, . 
it could be restored to its proper position by pressure, but immediately resumed its abnormal position 
when the pressure was relaxed. 

[ 25 ] 


The second case was of a gentleman of this city, and differed in no especial manner from the 
first, except that the dislocation was to the left, which would suggest a probable explanation of the 
affection. In the first case the gentleman was left-handed, while in the latter he was right-handed. 
Probably the deformity was caused, primarily, by pressure of the thumb in using the handkerchief. 
Subsequently, as the nostril became partially closed, more vigorous efforts at clearing the occluded 
passage would be attempted by closing the opposite side by the thumb, and thereby the deformity be 

The operation in each was the same, and consisted in the removal of the cartilage. This was 
done by making an incision along the edge of the protruding mass with a gum lancet, which I found to 

answer an admirable purpose, and dissecting down until it was sufficiently cleared to enable me to seize 
it with a pair of rat-tooth forceps. The dissection was then easily completed, and the cartilage 
extracted. A small elliptical piece of redundant muco-cutaneous membrane was then cut out with a 
pair of scissors, and the wound closed with two fine sutures. In each case the parts healed by first 
intention, the sutures being removed on the second day. No anaesthetic was used, and the operation 
was not especially painful. The results were eminently satisfactory, the deformity being completely 
removed, and absolute symmetry restored. 

L 20 ] 








Aural Surgeon to the New TorJe Gilg Eye and Ear Infirmary. 

Case I. — Facial paralysis of the right side-caused by necrosis of the petrous bone, occurring in 
a case of chronic purulent inflammation of the middle-ear: — see Plate IV., two upper figures, the 
patient in repose, and the same patient endeavoring to laugh. 

The case was a woman, nineteen years of age. When about ten years old she experienced buzz- 
imr in the right ear. Coming for treatment in November, 1880, she stated that the ear never dis- 
charged until six months previously; commencing after “ pains and a gathering ” in the ear. Four 
months ago she caught a severe cold in the head, and one week afterwards she found on getting up in 
the morning that the right side of the face was paralyzed ; the mouth was drawn to the left, and she was 
unable to close the right eye. She was not suffering pain when she came for treatment, but previously 
she had suffered much from neuralgia in the right temporal region, perhaps partly from dental caries. 
For the past four months the attacks have been of a more distinctly paroxysmal character. For the 
past two months she was never free of vertigo, and was in constant fear of falling backwards; her -'ait 
is staggering. When pressed for a statement respecting the duration of the aural disease, she admitted 
that the ear had always had a bad odor. 

On examination, a large polypus was seen to almost fill the right external auditory canal, and 
the probe detected the presence of a detached sequestrum of bone deep in the canal. The polypus, 
which was attached to the superior posterior wall of the canal, near its outer extremity, was removed by 
the snare, and the sequestrum was immediately afterwards brought away by the foreign body forceps. 
The latter came away with difficulty, although the external auditory canal was fortunately very 
large. The sequestrum, when examined, proved to consist of a plate of irregularly rounded bone about 
one-fourth of an inch in diameter, one portion of which was very thin, and the other nearly a quarter of 
an inch in thickness. This sequestrum was examined by Prof. J. D. Bryant and myself, and is believed 
to consist of the roof of the tympanum and a portion of the mastoid body just external to the hiatus 

[ 37 ] 


Fallopii. A ridge on the specimen corresponds to the anterior ridge of the groove on the superior 
border of the bone located beneath the superior petrosal sinus. The reticulated arrangement in the 
cavity of the specimen has the general arrangement of the reticul® of the antrum mastoideum ; besides 
which, the relations of the compact and cancellous tissues are such as to exclude its having been 
located elsewhere. The superior surface of the sequestrum, where it came in contact with the dura 
mater, was roughened by caries. 

After the removal of the sequestrum, another large polypoid mass was taken away from the 
ear, leaving a very large cavity at the junction of the canal and the posterior wall of the tympanum. 

At the bottom of this cavity was a mass of granulation tissue, which, under the use of 
powdered acidum boracicum, soon disappeared, and the discharge ceased. The facial nerve, when 
tested by Dr. McBride, did not respond to either galvanism or faradism, although at first the muscles 
of the face gave degenerative reaction. 

In this case, the facial nerve was undoubtedly impaired before the chorda tympani was given 
off, for there was very decided modification of the sense of taste on the right side of the tongue. 
The palate was unaffected. The palsy has been treated by the galvanic current, but with slight 
improvement. Hearing was not entirely lost. The patient is at present free of vertigo and tinnitus 
aurium, but has occasional headaches, owing to a rather broken-down condition, and the continuance 
of oral and naso-pharyngeal irritation. 

Case II. Bilateral facial paralysis occurring in a case of sudden deafness from syphilis : — see 
Plate IV., two lower figures : the patient in repose, and the same patient endeavoring to close the 
mouth and eyes. 

This patient was a man 40 years of age, who contracted syphilis in the summer of 1879, and 
was treated in Charity Hospital. Three months later, having taken a severe cold, he had paralysis of 
the right side of the face. Three months after this attack — and six months subsequent to the syphili- 
tic infection, he was again very much exposed in a cold rain-storm, and went to bed with a severe 
cold ; on getting up the following morning he experienced so much vertigo that he could only walk 
with difficulty. While eating his breakfast, he found that he could open his month only wide enough to 
admit a spoon between his teeth. A facial paralysis of the left side had now occurred, and the inability 
to get food into the mouth was owing, doubtlessly, to the unique employment of the unaffected muscles 
used in mastication. 

The patient at this time experienced severe pains in the right side of the head. Soon after the 
experience above related, as taking place at breakfast, while trying to converse with a friend, he found 
himself to be perfectly deaf in both ears, since which time he has been unable to hear a single word, 
however loudly spoken. The patient was not conscious of any deafness following the first attack of 
paralysis on the right side. 

When the patient first experienced difficulty in opening the mouth, he fancied that he had 
“lock-jaw,” and he then ascertained that instead of the face being drawn to the left, both sides were 
now alike. Following both these paralytic invasions he experienced distressing tinnitus aurium, which 
continued up to the time he was seen — some eighteen months after the initial attack. He also suffered 
greatly from pains in the head and vertigo until a short time before I saw him. lie could not, of 
course, either whisper or whistle. No treatment was attempted. 

[ 28 ] 



T1 ie view of this patient when the face was in repose gives the characteristic facial expression 
in this affection ; the eyes have a horridly staring look, while the entire face is an expressionless blank. 
When trying to explain the symptoms of his case the difficulty experienced in enunciation, together 
with the nasal tone and collapsing of the nostrils — the latter preventing the entrance of air into the 
nose — caused the patient to exert himself in a most painful manner, yet the face gave no evidence of 
the struggle taking place. The absence of nearly all of the teeth rendered articulation still more 
difficult. When an effort was made to close the mouth and eyes, the former was accomplished by the 
action of the temporal, masseter and internal pterygoid muscles; the patient was, however, inclined to 
use his hand when requested to bring the jaws together. It was not possible to close the eyes, but he 
was able to roll them upwards and inwards, the lower lid remaining inactive, the upper lid dropping 
down slightly by its own weight ; the effect of the display of the lower portion of the cornea between 
the widely separated lids was ghastly in the extreme. Fortunately for these cases, the levator palpebrse 
not being supplied by the facial nerve, the upper lid can be raised from the eye. 

The cause of the paralysis in this case is somewhat in doubt. There is a possibility that the 
morbid process which gave rise to it may have been at the base of the brain ; if so, it was probably 
syphilitic. There are reasons, however, for believing that the cause w T as peripheral, the most impor- 
tant of which are the aural symptoms ; the attacks followed colds during which there were pains in the 
neighborhood of the ear and disturbances of the functions of both the transmitting and perceptive 
regions of the ear. The exact seat of the lesion, if peripheral, cannot be told, for there were but 
slight morbid changes in the ear perceptible to the eye, and the patient did not return again to have the 
sense of taste, etc,, tested.* 

The symptoms accompanying Bell’s paralysis are so familiar to the profession that I shall only 
venture to offer the above cases as a contribution to the literature of the subject, and as pointing to 
diseased processes about the ear as a frequent cause, leaving the discussion of the strictly neurological 
aspect of the disease to those who make a special study of the subject. The nearness of the 
aqueductus Fallopii to the middle-ear, which is well known to be specially obnoxious to colds, 
would seem to account for the frequency of paresis of the facial nerve in disease of the ear 
rather than cold affecting the nerve after it has left the stylo-mastoid foramen. It is well known 
to otologists that grave aural disease may exist for a long time without implicating the facial nerve : 
— and is it not probable that the Fallopian canal may, in some instances, from its defectiveness, afford 
inadequate protection to the nerve ? 

* For other features of this, especially as regards the hearing, see American Journal of Otology, vol. II., p. 304. 

[Note. In the artotype illustrations the right and left sides are transposed us in a mirror.] 

[ 29 ] 




Assistant Surgeon, New York Ophthalmic and Aural Institute. 

This disease lias been described under various names, as Symmetrical Opacity of the Cornea, 
Transverse Opacity, Transverse Calcareous Film of the Cornea (Nettleship), and Ribbon or Band- 
Shaped Keratitis. 

It is of rare occurrence, and the best description of the disease, with an analysis of twenty-two 
cases, may be found in the Archives of Opthalmology, Vol. viii., No. 3, p. 293, et seq., contributed 
by Edward Nettleship, of London. 

The following case, of which the drawing is a beautiful illustration, came under my notice 
several years ago, and is one of the few cases of the kind which I have seen. 

The patient was a German, about fifty years of age, and of apparent 
good health. I remember, especially, that he had no tendency to gout or 
rheumatism. I did not cpiestion him as to syphilis. In the right eye, which 
is represented in the cut, the disease began a number of years ago, and was 
first noticed as an opacity at the margin of the cornea, on each side, which 
gradually grew towards the centre, and then began to very seriously affect 
his sight. 

On looking at the eye without raising the lid, a transverse grayish- 
brown opacity seemed to occupy the entire palpebral fissure. The band 
of opacity does not exactly follow the horizontal meridian, but crosses 
the cornea rather obliquely. It is much broader at the margins of the cor- 
nea, and gradually grows narrower toward the centre. By oblique illumina- 
tion the epithelium of the cornea does not show any alteration, but appeal's 
quite normal. The opacity has a stippled appearance, and in places shows fissures or cracks. The 
opacity does not quite reach the borders of the cornea, although it is incorrectly represented to do so 
in the cut. 

The pupil is almost concealed, except just the outlines of its upper and lower borders, which 
become a great deal more apparent when a solution of atropine is put in the eye, and it is then seen, as 
shown in the figure, that there is a synechia at its lower margin. Objects held above or below could 
be seen, but I have no accurate record of the acuteness of vision. In the left eye there were two 

[ 30 j 


patches of opacity, just beginning near the corneal margin of both sides. This eye was in other 
respects normal, and vision good. 

I proposed to the patient an iridectomy on the left eye, which would certainly have very much 
improved his vision, but he declined all treatment, and I never saw anything further of the case. 

The above Case is quite a typical one, and illustrates very well the usual course of the disease. 
It seems quite evident to me that the disease should not be considered as an inflammatory one, and 
hence I would not speak of it as a keratitis. On the whole, I prefer the name suggested by Nettle- 
ship. The opacity may begin either as a single patch of opacity in the centre or at the sides of the 
cornea, or as in my case, as a patch at both sides, which gradually coalesce. The form in which it 
begins in the centre and grows towards the margin is rarer. The opacity is beneath the epithelium, 
which remains smooth, shows the usual bright reflex, and ulceration is never present. The course 
of the opaque band is not exactly transverse, but always slopes a little from within outwards and 
downwards, and the uncovered parts of the cornea are sharply defined. Nettleship says that the 
majority of cases remain free from complication for many years. But in all of the cases which I 
can remember seeing, three in number, complications of some sort existed. In the one now reported, 
the posterior synechia shows that iritis was present at some time. In one other case, which I saw some 
years since in the New T ork Ophthalmic and Aural Institute, there was chro lie glaucoma in both eyes, 
with great increase of tension of the eye-ball. In the other, a girl of twenty, whom I saw in 1878 at 
the Columbus Blind Asylum — by the way, the youngest subject in which I have seen the disease, and 
younger than any of the cases analysed by Nettleship, the youngest being twenty-five — the second eye 
was lost by cyclitis. A case has, however, recently been reported by Lewkowitsch, in the Ivlinische 
Monatsblatter fur Augenheilkunde, vol. xix., p. 250, of ribbon-skaped keratitis in an eye with a large 
and immovable pupil without any other abnormality. The other eye was normal. The writer speaks 
of the case as unusual because of the absence of other abnormalities. 

Although the disease usually begins first on one cornea, it always becomes symmetrical in the 
end. Facts as to this statement are given by Nettleship in his cases. As to the character of the 
opacity scrapings removed from the cornea and submitted to microscopical examinations have been 
found to consist of phosphate and carbonate of lime. Both Mr. Dixon* and Mr. Bowmanf succeeded 
in greatly improving sight by the removal of the opacity in this tvay from the centre of the cornea. 
The pain felt by the patient during the operation proved the fact that the epithelium was not destroyed 
by the disease. This plan of treatment, the solution of the deposit by some chemical substance, and 
the operation of iridectomy, embrace the various methods of treatment which have been suggested. I 
confess my preference for the last-named plan, and would especially use it as the best when either 
synechise from iritis or glaucoma exists as a complication, because of the well-known benefit which the 
operation is known to have in such cases. 

Nettleship gives a careful analysis of the cases upon which his paper is based with reference to 
theh aetiology. But it seems to the writer, even from the analysis which he gives of the facts as to the 
constitutional state and morbid tendencies, his view that the affection is closely allied to gout is hardly 
carried out. Of the twenty -two cases most proved to be in good health, when seen, four were said to 

* See Dixon’s Diseases of the Eye. 

t Bowman on the Parts concerned in the Operation on the Eye. 


be thin, dry-fibred and sallow, one only plethoric. In two there was a family history of consumption. 
There was a definite history of gout either in the patient or of his father in four cases, and in one other 
the patient though not gouty was a painter. In five other cases, although no gout was present, the 
patients had other changes in the eyes, which are, the author says, closely allied to gout, iritis, glaucoma, 
hemorrhagic retinitis. One died with granular disease of the kidneys, hypertrophy of the heart, and 
pulmonary apoplexy, with widely diffused and abundant atheroma of the arteries, at the age of fifty- 
three. He had never had gout, and the absence of gouty changes is especially mentioned in the notes 
of the post-mortem. In five more there is no mention made of the state of the patient’s health. 

Nettleship follows this analysis with some facts, and queries what he thinks may be considered 
'i" favor of local or constitutional causes to these we can only just allude. In favor of local cause 
(a) The opacity never invades those parts of the cornea which are habitually covered by the lids, (b) A 
margin of cornea at each end always remains free from the opacity, (c) It will be worth while to 
inquire whether, from decrease in sensibility of the cornea, such patients sleep with the eyes partially 
open or wink less often than other persons. Such peculiarities would allow of a freer evaporation from 
the exposed part of the cornea, and might therefore lead to collection of any solid residue at this place. 
(<l) Is it due to a superficial inflammatory change leading to calcification t (e) Can the disease be partly 
explained by natural differences in the closeness or permeability of the corneal tissue, or in the thickness 
of its epithelium in different persons ? 

In favor of a constitutional cause, (a) Although the opacity forms in an exposed part of 
the cornea, it occurs in so few persons that there must be some special conditions added ; such as alter- 
ation of the eye fluids and therefore probably of the blood. 

(c) The history of gout in one case, and in the parents of several more, and the occurrence of 
diseases usually attributed to gout, seem to point to it, or to the excess of uric acid in the blood as a 

(d) Is any corresponding (not necessarily identical) change met with elsewhere in the skin ? 

(e) Is the disease met with in the lower animals ? 

( f ) In what relation does the corneal change stand to glaucoma and iritis when these occur l 

In concluding his article this author distinguishes between the present disease and the formation 
of a stripe of opacity of a somewhat similar character which occurs in eyes which have been for a 
long time blind. The pathological appearances, too, are different in the secondary baud shaped opacity. 
Goldzieher found them to consist of colloid formations in the superficial layers of the cornea, irregular 
thickening and degeneration of the epithelium and the presence of masses of fat in the deeper layers 
(Hirschberg’s Central Batt., Jan., 1S79. Quoted by Nettleship). 

Reference has been made to but a few of the points of interest in this peculiar affection, and 
those which I have thought most likely to interest the general reader. To those who may desire to 
become more familiar with the subject, I would recommend a perusal of Nettleship’s paper, which 
is a most exhaustive study of the subject. His paper has an appendix with the names of authors and 
an abstract of all recorded cases in the order of their publication. I have only been able to add four 
cases to bis list, the one here reported, two others observed by myself, mentioned in the paper, and that 
of Lewkowitsch. 

[ 32 ] 



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Emeritus Professor of Obstetrics and Diseases of Women and Children , and President of the Faculty of the 

Bellevue Hospital Medical College , New York. 

This pathological specimen of aberrant pregnancy came under my notice some years since. 

A female between twenty-four and twenty-five years of age, married only a few months — 
general health good — regular every month, had passed her last period about two weeks, and considered 
herself four or five weeks pregnant. The ordinary signs of gestation, though slight, existed. At this 
time she was affected with severe vomiting, accompanied with intense pain over the uterine and left 
ovarian region. Under the treatment adopted she was materially relieved. The following day the 
uterine and ovarian pains returned, accompanied with fainting, when sudden collapse ensued, and the 
patient died. 

Autopsy . — The uterus was larger than in the unimpregnated state — was two and three-quarters 
inches in length, and one and three-quarters in breadth. The body of the uterus was rounder than nat- 
ural from the os tincse to the fundus ; the muscular structure was thicker than ordinary. There was no 
physiological hypersemia, noflocculent deposit, nor any decidua. The interior of the body of the uterus 
was paler than usual, except at the lower part of the cervix, which was congested in small vascular spots 
near the os tincse. The broad ligaments were slightly congested and were carefully removed to obtain a 
distinct view of the ovaries. The left Fallopian tube was very slightly attached to the ovary, by a small 
portion of the fimbriae, and was not very vascular. The tube was cut off near the uterus, and this was not 
more congested than the interior of the uterus. The ovary was very much enlarged, of a deep red 
appearance, especially at the uterine end. The small white spot of about two lines in length, indicates 
where the rupture occurred, and from which two or three pints of blood issued. The ovary measured 
one inch ten lines in length and one inch four lines in breadth. The distal end was more prominent 
and fuller than the uterine, but it was not as deeply congested. The epithelial covering was thinner, 
and gave no evidence of laceration. This tunic, as well as the tunica propria, was divided and turned 
back displaying the Graafian follicle, with its clear and transparent pearl-colored membrane, through which 
a small solid body could be seen. It appeared to be directly in apposition with the small circular white 

Text fok Plate V. — 1. Cavity of uterus, no decidua. 2. Cavity of cervix, congested. 3. Left ovary, highly 
vascular, and spot where rupture occurred. 4. Ovarian epithelium, and tunica propria cut open showing, 5. Enlarged 
Graafian follicle. 6. Thin transparent tunica pellucida or vitelline membrane, with a small body size of a pea attached. 
i. Right o\ary, very large. 8. The remains of three cicatrices. 9. Ovarian epithelium, dissected olf. 

[ 33 j 


spot externally, in the region of the vitellus. The follicle measured thirteen lines in length, and ten 
lines in breadth. The Graafian follicle was attached posteriorly to the ovary in one-third of its super- 
ficies, the rest was free. The right ovary was enlarged, the Fallopian tube was free and moderately 
congested at its extremity. The epithelial coat was divided and rolled over showing its slight lobulated 
appearance with three cicatricial points of rupture. 

Remarks . — Considering the number of these cases recorded, they cannot be considered so very 
uncommon, or as rare as abdominal pregnancy. Usually cases of extra- uterine foetation are tubal. "\ el- 
peau accepted the opinions of Blainville and Serres, who assisted him in dissections and investigations 
of the four supposed cases of ovarian pregnancy, and he states that “he had evidently been imposed upon 
in this matter.” The fourth case, however, there was great difficulty in deciding upon, after having 
carefully isolated the Fallopian tube. The debris of the conception was contained in a sac lying be- 
tween the peritoneum and the tunica propria of the ovary. In truth, the impregnation was on the 
surface of the germiniferous gland outside but not in it. Velpeau does not even, as he says, pretend 
that the ovum has never been observed on the surface of the ovary, but that when once verified, “ it 
has never yet been found enclosed in the envelopes of the organ as in a cyst.” 

We are all aware that the unimpregnated ovum is believed to leave the ripe Graafian vesicle in 
order to enter the fimbriated extremity of the tube, and descend into the uterus, in either of which it 
may become fecundated, being discharged either at the beginning of menstruation, after, or dur- 
ing its flow. The epithelial tunic at present is considered as nearly allied to the mucous coat of the 
tube, though without its cilia, and bathed in a peculiar liquid. Sometimes only a small part of the 
fimbria is in connection with the ovary, and the ovum may pass along some of its grooves or furrows 
to the tube itself. It is even considered as not necessary for any part of the fimbriated extremity to be 
in close apposition. These physiological laws are so amply verified, that it naturally suggests the ques- 
tion whether the ovum could not be impregnated before leaving the follicle, and establish a pregnancy 
in that organ, enclosed, “as in a cyst.” 

The ovum may during the act of connection be in the stage of development, and preparing to go 
through the process of delivery, when it is met by the spermatozoids and conception follow ; or it may 
be expelled from its cavity into the tube, or drop into the abdominal cavity ; or it may be arrested on 
its way ot delivery and before its escape, and become an ovarian gestation dwelling in the ovary itself 
“ as in a cyst.” 

It is not necessary, that the impregnated ovum should receive its nourishment or be attached 
to mucous surfaces. The germ may attach itself and live till it has completed its full term of intra- 
uterine existence in the abdominal cavity, without having any connectiou with the uterus, tube or 
ovaries. The ovum is nourished by endosmotic action. 

From the history of other cases reported at as early a period of pregnancy as my own (Kam- 
inerer, N. Y. Med. Journal, 1S65 ; I. G. Porter, Amer. Journal Med. Sciences, 1853), there can be 
no doubt of the embryo being enclosed in the envelopes of the germiniferous gland. Velpeau admits 
his was on the outside and between the peritoneal coat, or, more correctly, the epithelial tunic, 
and the tunica propria, and is an exceedingly rare place for gestation to be recognized. P>ut consid- 
ered as an impregnation, and covered by a peritoneal coat, the spermatozoids must have penetrated 
that membrane, and it lends confirmation to the facts advanced in these remarks. 

t U ] 





Clinical Professor of Diseases of the Mind and Nervous System , College of Physicians and Surgeons , New York. 

Progressive facial atrophy is such a rare disease that every case is worthy of being recorded. 

Case. — Delia II., aged ten years, was brought to my clinic for diseases of the nervous system, at 
the College of Physicians and Surgeons. The mother gave the following brief history : Delia had 
enjoyed good health as a child. At the age of five years there was noticed a greenish spot, “like 
a ringworm,” on the left check, midway between the malar bone and the angle of the mouth. There 
was no pain. In the course of one year, the cheek became depressed and the mouth crooked, being 
drawn upward and to the left ; no other spots were noticed. The disease has steadily progressed, 
without pain. General health and mental development have been satisfactory. 

Examination . — The child is well grown and healthydooking, 
but the left side of her face is disfigured by atrophy of a large part 
of the cheek. The angle of the mouth is drawn upward and to 
the left ; the upper red border of the lip on the left side is small, 
almost linear. The region between the mouth and the malar emi- 
nence is the seat of a depression capable of receiving half an English 
walnut. At a distance the skin appears healthy ; but closer examina- 
tion reveals the following points : a whitish spot exists in the centre 
of the atrophied region, about the size of a five-cent silver coin. 

The rest of the skin of the head, face and neck is normal. The 
deeper tissues of the cheek are much wasted, and the thickness of 
the cheek is less (one-third) than that of the opposite side. The 
very thin left upper lip, and the left cheek are not at all adherent to 
the subjacent bone. The rest of the left face is rather thin, but 
presents no positive atrophy. The tongue and soft palate are normal. The left superior maxilla 
is, however, much atrophied ; its alveolar process not being more than one-half as thick as that of the 
opposite side. The teeth are more regular on the diseased than on the healthy side ; they are of 
good size and fairly preserved; the space between the two upper middle incisors is abnormally great ; 
there is no syphilitic or rachitic peculiarity about them. The anterior portion of the hard palate is 

[ 35 ] 


deeper on the left side. The lower jaw is normal. The pupils are equal and normal. Motion is well 
pci formed in the atrophied left cheek, as well as in other parts. 

Sensibility.— . Esthesiometer points are differentiated on the forehead, of 15 mm. on either side, 
on cheeks at 11 or 12 mm. on either side, on the lower cheek and over jaw at from G to 10 mm., on 
the red surface of the lips 2 mm., equally well on both sides. Pricking is well and similarly felt 
on each side. The electrical reactions were carefully studied. First, to Faradism. Xervous reaction 
(Kidder’s induction machine), on right and left substantially equal, with minor current from posts 
a. it., and four inches of cylinder withdrawn, contractions obtained. Muscular reactions: one sponge 
on malar eminences and the other electrode on the lip or cheek, externally and internally, cause similar 
contractions on either side. Every muscle of the lip and cheek on the left side is present, and 
responds normally. Second, to Galvanism. With 8-9 elements reactions of nerves and muscles are 
normal ; on both sides jerky contractions and C O C C A X C C. 

Yaso-motor phenomena . — Except the whitish spot above described, no difference is to be noted 
between the cheeks ; when the patient blushes both sides of her face and head are equally suffused, 
and the same is true of the effect of nitrite of amyl. The mother of the patient thinks that she 
does not perspire in the wasted region. 

A treatment by galvanism, cathode placed strobile on the wasted region for five minutes with 
a medium current was faithfully carried out for several months without result. The patient was not 
again seen until January 14 of the present year, when the following notes were taken. 

Patient is large and well-developed, has menstruated normally for a few months. 

The left cheek presents very much the same appearance, except that the spot of discoloration 
is no longer visible. The atrophy lies between the left malar eminence and the mouth, and involves 
the subcutaneous fissures of the cheek and left upper lip, and the left upper maxilla, in its palatal 
and alveolar parts. The wasting, both in bone and lip, reaches just to the median line. Can purse 
lips and draw mouth upward and backward well ; the muscles of the atrophied region acting as well 
as those of the healthy side. 

Sensibility . — To the lightest finger-touching test patient thinks that she feels less acutely 
in the left infra-orbital and mental regions than on the right, but the esthesiometer reveals no differ- 
ence — both sides are normally sensitive. States that when she washes her face she feels the coldness 
of the water equally on both sides. 

Faradic and Galvanic tests were carefully made, and showed no qualitative change in nervous 
and muscular reactions. To Faradism with a metallic electrode within the cheek, the muscles within 
the atrophied region contracted more quickly and fully than those of the healthy side (with the same 
weak current). This was probably due to diminished resistance in the affected cheek by the dis- 
appearance of the skin and some areolar tissue. ■ The patient’s mother states that she now blushes 
equally on both sides of the face. I did not feel justified in harpooning the face for muscular fibres, 
hence can make no statement upon their condition. 

One case has been published by l’rof. AV\ A. Hammond. The patient was shown to the Xew 
York Xeurological Society, and Dr. Hammond stated that the muscular fibres ot the atrophied region 
were smaller than those from corresponding muscles on the healthy side; but showed no degenerative 

[ 30 ] 






Professor of Anatomy , College of Physicians and Surgeons, New YorTc. 

Thomas Colt, age 25, IT. S. 

Patient entered Bellevue Hospital in 1871, with so-called lupoid (?) ulceration of face. This 
finally healed after having destroyed the nose, both lower eyelids, part of the lips, especially the upper, 
and part of cheeks. He came under my 
notice in 1878, at which time he presented 
the appearance seen in the two upper pho- 
tographs of plate YI. The corner, from 
constant exposure, had become hazy, so 
that' he was unable to read, and the mouth 
could be closed but little more than is seen 
in plate YI. I felt disinclined to do any- 
thing, as the tissues to be operated on were 
cicatricial, and I feared that the old disease 
might return. I heard nothing from him 
for some months, when he again applied to 
me. I consented to do an operation for 
restoration of the right lower lid, intend- 
ing to be guided by the result of this as to 
any further proceedings. 

May 28, 1S78. — Fig. 28. — An in- 
cision ABCD, was made, marking out a 
flap which was dissected up as far as AD. 

The skin Avas then removed from the semi- 
circle a, and the flap doubled upon itself 
along the dotted line and raised in such a 
way that the surface above the dotted line lookqd backwards toward the eyeball, the surface below 
looked forward, the part at dotted line forming margin of the lid ; b fitted into a ; which part of the 

[ 37 ] 

Fis. 28. 


operation was done for the purpose of holding the lid in place. By thus raising the flap, a raw surface 
was left which had been occupied by the part of the flap below the dotted line. To till this, and to 
hold up the lid, an incision BEFG was made and the flap dissected up. It was then turned at a right 
angle and stitched to the margin of the space to be tilled, BE coming to BC (winch had been raised to 
height of dotted line), EF to lower part of DC, GF to cheek part (as distinguished from flap part) 

of BC. 

By dragging the flap BEFG 
into its new position, the raw surface, 
which would have been left at the part 
from which it was taken, was nearly 
closed, the portion of the flap G having 
been drawn to B, and the closure was 
completed by stitching GF to BE. As 
this left the skin of the cheek below 
FE puckered, the triangle FILE was 
removed and FI1 stitched to FBI. 

The result of this operation was 
so good that a nearly similar one was 
done on the left side. 

October 3, 187S. — After these 
operations the corneal haziness nearly 
disappeared, and the patient was able 
to read the finest print. 

December 19, 1S78. — Operation 
for relief of deformity of mouth, 
Fig. 28. An incision passing entirely 
through the upper lip was made from 
A to B. This flap was dragged down 
so that A could be brought to E, leaving a triangular space where AB had been. Incisions EACD 
were made and all the tissue between AE and margin of left side of lip removed. The point A of 
the lip flap was then stitched to the angle of the mouth E, and the triangular flap ECD, which had 
been dissected up, fitted into the triangle left by the pulling down of lip flap, C coming to B, DC 
to upper edge of AB and EC to lower edge of AB. The raising of flap ECD of course left a raw 
surface at this part which was easily closed by stitching upper part of CD to CA. 

June 20,1879. — Operations to relieve deformity of inner canthi. The overhanging skin at 
each canthus was slit toward but not as far as median line, the incision dividing also the conjunctiva on 
the under surface of fold and the tissues between. The edges of the incision then separated, thus 
enlarging the palpebral fismre. Along the edges the skin was stitched to conjunctiva. 

November 1, 1S79. — The patient being very solicitous to have a nose made, I explained to him 
that the usual operation of taking a flap from neighboring or distant parts would be useless as there 
was no bony frame-work to hold it in position, and that it would consequently shrivel to a mere knob 

l 38 ] 


of skin. Knowing of a case reported by Hardie, of Manchester, England, in which he had made use 
of the last phalanx of the left forefinger to form a nose, the idea having been suggested to him by his 
house-surgeon, Mr. Tytler, I offered to do a somewhat similar operation if my patient would assume his 
share of the risk, which was that the operation might fail, and he would then have lost a finger and 
still have no nose. He expressed willingness to lose a second finger if the first 
operation should fail. 

The last phalanx of middle finger of left hand having been frozen, the 
nail was torn out and the matrix scraped and burned with nitric acid. 

December 12, 1879. — -The surface from which the nail was torn has 
healed, the matrix having been apparently destroyed. 

A plaster of Paris jacket was fitted to the chest, and when hard was slit 
up at one side, so that if difficulty of respiration should occur during the 
operation, it could easily be removed. Tins was joined to a plaster of Paris 
helmet, which covered the upper surface and sides of head, and back of neck. 

A curved incision, AB, Fig. 29, was then made, and the skin and fascia 
detached from parts beneath, so as to form a pocket represented by the dotted 
outline. Incisions BDFH and ACEGi were then made, the edge of knife 
being directed deeply toward the middle line, to enable the edges of the two 
flaps to be turned toward the median line in such a way that the under raw 
surfaces of the flaps would look nearly forwards. The skin was then so dissected 
off the flaps as to present two raw surfaces. Figs. 31 and 32. 

From the lower half of last phalanx the entire skin was removed. Fig. 30. 

An incision was made along the middle of the palmar surface of the second and upper half of the third 
phalanx, and two transverse, one opposite the palmar surface of the first phalangeal articulation, the 
other opposite the middle of the last phalanx. These transverse incisions passed about one-half round 
the finger. The finger flaps thus formed were dissected up as deeply as the sheath of the tendons. 
A silver suture, armed with a needle at each end, was then passed transversely through finger near the 

tip. The needles were passed into the pocket, brought out at X, and traction being made on the wire, 
the finger tip was drawn up into the pocket, in which it was concealed. The ends of the wire were 
then twisted together, holding the finger in place. The edges of the finger flaps were then stitched 
to BDFH and ACEG the under surface of the face flaps coming against the under surface 
of the finger flaps, and the denuded skin surface of the face flap coming against the raw side and 
palmar surface of finger. Fig. 29. After the finger had been partly stitched to the face, the patient, 
who had become more and more cyanosed, stopped breathing. A laryngotomy was done, and artificial 
respiration made, so that he soon breathed easily. The stitching of the flaps was then finished. 

[ 39 ] 


In Fig. 30 is seen the finger, ready to be placed in position, with the lower half of the last 
phalanx denuded of skin, and the flaps thrown outward, ready for application to the face. 

Fig. 31 shows a transverse horizontal section of part of the face. X indicates the nasal opening 
(it should not be closed at the lewer part, as it communicated with the naso- pharyngeal space). 
AB and CD mark the incisions backward and inward toward the median line, making flaps on each 
side, BAE and DCF which were turned inward. The skin from surfaces AE and FC was dissected 
off, so that each flap had two raw surfaces, AB and AE and CD and CF. 

In Fig. 32 can be seen how the finger flaps and face flaps came together. AA'B is the line of 
junction of the under surface of finger flap and raw surface of side of finger with the face flap. A'B 
being the part of face flap from which the skin had been removed, and which, being turned somewhat 
inwards, came in contact with the side of the finger, and not with the under surface of the finger flap. 
The hand and arm were then fastened to the jacket and helmet by plasters and bandages. 

The patient was fed through a tube introduced beneath the hand at the right corner of the 
mouth, until the finger was amputated. The jacket and helmet proving irksome were removed on the 
sixth day, and the hand was afterwards held in place by adhesive plaster and roller bandages. 

As the finger was nourished through the digital arteries, and probably but little through the 
adhesion between the face and finger, it was thought necessary to compel a proper supply between the 
face and the finger. On January 3, 1880, an elastic ligature was passed round the finger opposite 
the lower part of the first phalanx. On account of pain this had to be removed in a few hours. 

Jan. 5, 18S0. The end of the finger has not united to the pocket. From retraction of the 
pocket flap and slipping down of finger the tip is exposed to view. 

Jan. 8. A needle armed with a silver wire was passed deeply through the right side of the 
finger beneath the digital artery, and the two ends of the wire attached to a Wood’s varicocele clamp. 

Jan. 1G. Wire removed. Jan. 22. Left digital artery secured. Jan. 25. Left wire removed. 

Jan. 27. An incision was made down to the bone on the sides and palmar surface of finger. 
After this had been done the finger became pale, and the amputation was postponed. 

Jan. 30. With the assistance of Dr. Sayre the finger was amputated, with knife and bone 
forceps, at the middle of the first phalanx. The stump of the finger attached to face bled freely, 
showing that the circulation was good. The part of the first phalanx attached to the finger was bent 
at right angles, so that the amputated surface looked backward, the part of the first phalanx attached 
to finger thus forming a septum for the nose, the first joint forming the tip. 

Oct. 8, 1880. The finger tip now lies in front of the space between the inner canthi. The 
matrix was not destroyed as was supposed, as the nail has partly reappeared. It was softened with 
caustic potash, removed with forceps, and the matrix scraped. 

Dec. 28. The skin over the site of the matrix was removed, and the tip of the last phalanx cut 
off with bone forceps. A small flap was then slid down, and fastened on the denuded finger tip. 

Since the above note several minor operations have been done which it is not necessary to 
mention in detail. At the present time the finger has sunk downward a little, so that the lower 
eyelids are somewhat dragged upon. The amputation of finger should have been done nearer the 
hand, as the tip of the nose is not prominent enough, partly from atrophy of that part of the first 
phalanx attaehed to finger, and partly from the sinking backward and atrophy of the Huger itself. 

[ 40 ] 



Surgeon to the Out-Patient Department of the New TorJc Hospital ; Consulting Physician to the Hospital for the Ruptured 

and Crippled. 

In 1832 Dupuytren distinguished, among the many deformities and contractions of the hand, one 
that was characterized by a drawing down of one or more fingers toward the palm, by a firm band ex- 
tending subcutaneously toward the wrist. It developed slowly, was not preceded by cellutitis, nor by 
injury, and came almost exclusively in men usually past middle life. 

It is four years since Mr. Adams of London again drew attention to the malady, and proposed 
for its relief the simple and perfect expedient of subcutaneous division of the contracted band. British 
Med. Journal, June 29, 1878. Dupuytren and others had advised open operations, which were not 
always successful and often were disastrous. 

The case I am about to relate is a perfect type of this rare trouble, and presents one or 
two features of special interest. The patient, rather a large man, aged forty-five years, came to me 
June 9, 1881. He had been a cloth cutter for fifteen years. He had never had syphilis, rheu- 
matism or gout. His occupation required the use of large scissors in his right hand but nothing 
in his left. 

Seven years ago the left little finger began to draw down toward the palm without known 
provocation, and had grown progressively worse, until it rested flat on the palm though it could 
be raised by a little ±orce to the extent shown in Fie;. 33. 

v o 

One year ago the ring finger of the right hand began to contract in the same fashion and 
had progressively become worse until it was as shown in Fig. 34. Of late it became such an 
inconvenience and so painful tnat it prevented his working. To all appearance there was a 
tendinous band as of the flexor tendon rising from its bed, stretched tightly beneath the skin of 
the palm from the base of the second phalanx of the affected finger in each hand, well up towards 
the wrist. The skin along this band was puckered and intimately bound to it. The joints of the 
affected fingers were apparently not ancliylosed, but extension beyond the amount shown in the figures 
was prevented by the band referred to. Careful study made it evident that these were each a 

[ 41 1 


fasciculus of the palmar aponeurosis tightly contracted, intimately related to the skin in parts, and 
lying above the flexor tendon, which was not diseased. 

On June 9th 1 resorted to Adams’s operation on the little Anger of the left hand (Fig. 33), 
dividing the band at two points *in the palm near the root of the Anger, where it was most tense and 
accessible. I did this without ether, and on account of the pain the patient refused to let me make a 
third division of a Intend band, on the outside, which prevented complete extension by about thirty 
degrees only. The greater part of the deformity, however, had been repaired by the two cuts. The 
Anger was bound in extension upon a posterior padded splint. Five days later it was found capable 
of flexion and extension through the limits gained by the operation. But another unexpected result 
was reported of which the patient volunteered this statement. For two months the band in 

the right palm had been so constantly in pain 
that he could not move this hand up to touch his 
head without almost unbearable suffering, and at 
times, especially if the palm was struck, it was 
very painful. Directly after the operation on 
the left hand the right ceased to hurt and he has 
found that he can now lie at night with his right 
hand behind his head and sleep on it without 
pain, which lie has not been able to do for 

On June 21st I operated under ether, 
making subcutaneous division of the band in the 
right palm at flve points half an inch apart. Its 
adhesion to the skin made this number necessary 
The Anger was well released, straightened out 
parallel with the others, and subsequently re- 
gained suppleness and freedom. The joints and 
tendons were intact. The patient lias been 

watched for half a year and no recontraction has taken place. He resumed his work of cloth cutting 
and has now no pain or return of trouble. In cutting I used the small tenotome of the ophthalmic 
surgeons, and much prefer it. 

It has been proved that the mechanical extension devices fail to overcome this contraction, and 
that there is no tendency to recontract after operation as there is in burn cicatrices. Adams believes 
this malady can almost always be traced to one constitutional origin, namely, gout. Bryant thinks that 
from its occasional symmetry it has probably a constitutional and not a local origin (injury). From 
the clews derived from the history of this case, I am inclined to think there may be a central nervous 
origin. The right hand became affected after the left had been progressing several years, and 
was most curiously relieved of all pain by operation on the left, giving strong suspicion of a reflex 
relation between the two. I may say, however, that there were otherwise no ataxic symptoms. 

t 42 ] 


b ( }r.s< ()/ '/)/: i . / J (ir bn f \ ) 





Of the Hospital for the Ruptured and Crippled , Hew York City. 

The accompanying plate represents the appearances found post-mortem in a male child set. six 
years, the clinical notes of whose case have been presented to the New York Pathological Society. 
Yet in view of the reproduction of the sketch made at the time of the autopsy, I propose to briefly 
give the more important facts in the case, that its pathology may he the better understood. 

The boy had marked deformity of the spine from caries of the vertebrae of eighteen months, 
and paraplegia of four months’ standing, when he came into hospital, August 18, 1S7L The 
paraplegia was marked by the characteristics of Pott’s disease : viz. : complete loss of voluntary power, 
very little atrophy, reflexes exaggerated even to the exhibition of spinal epilepsy, &c. Symptoms of 
profound myelitis were developed, bed-sores forming over the nates and thighs ; pulmonary hyper- 
semia produced, at times, very alarming symptoms, and he finally died, thirteen months after admission 
to hospital, seventeen months after the invasion of the paraplegia, and two years and seven months 
from the inception of the disease. 

The treatment consisted of mechanical support for the head and spine, counter-irritation, 
massage, tonics, &c. Dr. Jane way assisted me at the autopsy. The angular deformity of the spine 
extended from the first to the twelfth dorsal vertebrae, the apex being at the seventh. The various 
organs presented nothing worthy of note in this connection. Within the spinal concavity lay a tumor, 
two inches high and three and a half inches broad. This was an abscess, the contents of which had 
degenerated into a white, cheesy mass, well shown in the left hand figure of the plate. Its walls were 
formed by the anterior common ligaments, thickened connective tissue and the pleura. On vertical 
section no trace of the the body of the eighth dorsal vertebra could be found, and only small portions 
of the bodies of the sixth, seventh and ninth. Pultaceous matter occupied the place of the body of 
the eighth vertebra, and pressed on the spinal cord, which at this point was anaemic to a high degree, 
yellow, and very small. The absence of blood vessels in this compressed portion was notable. The 
greater portion of the cord was removed, and the sketch made without delay. The cord was placed in 
Mueller’s fluid, and was well preserved eighteen months later, when Dr. Seguin kindly made a micro- 

[ 43 ] 


Bcropical examination, cutting specimens from 1, the cervical enlargement, 2, the upper dorsal region 
four-fifths of an inch above the limit of compression, 3, the same distance below the lower limit of 
compression, and 4, from the lower part of the lumbar enlargement. 

“ The above sections were examined in two ways : 1. In a saturated solution of acetate of 
potassa, without staining. This was to show the granular bodies. 2. By Clarke’s method, to show the 
atrophy of nerve tube in parts, and the sclerosis of the neuroglia. Sections Xo. 1, treated by acetate of 
potassa, showed very exquisitely the lesion of ascending degeneration. The columns of Goll, or pos- 
terior median c >lumns, were filled with granular bodies. Sections Xo. 2, seemed quite extensively 
altered, granular bodies being found almost throughout the section — probably from pressure causing 
ischaemia of the parts. Besides the above, granular bodies were found in small number in the external 
part of the posterior lateral columns — the ascending cerebellar fasciculi of Flechsig. 

“ Below the seat of pressure, sections 3 and 4 showed the usual descending degenerative 
changes in the white columns, the mass of granular bodies occupying the outer and posterior part of the 
anterior lateral columns. The sections prepared by staining with carmine and by Clarke's method 
afterward, showed the same ascending and descending degeneration, evidenced not by granular bodies, 
but by atrophy of nerve fibres and increase of the neuroglia. Xo lesion existed in the gray matter, and 
the cells of the anterior horns seemed normal. In other words, this examination shows that except at 
the seat of pressure, there were no lesions other than those of ascending and descending degeneration.” 

This case illustrates the now accepted theory of the production of paraplegia, and the different 
tissues successively attacked. First we have the carious ostitis of the bodies of the vertebrae, then by 
contiguity, an extension of the morbid process of the perimeningeal areolar tissue, the vertebral liga- 
ments, and the dura mater. This gives us the “ paclnymeningite externe ,” which is characterized by 
vegetations on the external surface of the dura mater, and by consecutive carious alterations which 
blend with the carious detritus in the bone. The cord, consequently, becomes compressed, a focus of 
myelitis is induced, and from this focus a tranverse myelitis arises. This is followed by a fasciculated 
sclerosis ascending through the posterior and descending through the lateral and anterior columns. 
It is not necessary to have any angular deformity ; the hospital records containing the history of 
several cases wherein complete paraplegia existed, and yet no bony deformity was found. Such 
cases are, however, exceptional. Pressure is often removed by the formation of an abscess, and 
recovery from the paralysis ensues, sometimes quite unexpectedly. Subsequent restoration of motion, 
in cases like this one, is the result of re-establishment of the circulation in that part by the removal of 
pressure. Xo fact is so well established as this one, viz.: that cases of paraplegia, with evidence of 
lesions as grave as those I have mentioned, do recover. “ It must be remembered that the sclerosis 
involves the neuroglia, and that the secondary degeneration takes the place of the white fasciculi con- 
necting the nerve tubes. Even should the envelope of myeline be destroyed, impulses can be trans- 
mitted through the axis cylinder, and should this be destroyed, the degeneration existing in tracts or 
bundles, other nerve tubes which remain intact may serve for the transmission of impulses.”* 

* “The Paralysis of Pott’s Disease,"’ Journal of Nervous and Mental Disease, April, 1878. 

[ 44 ] 





Orthopedic Surgeon to the Out-Patient Department of the New York Hospital. 

Case I. — Was of a boy, get. six years, who presented an enormous abscess and all the usual 
symptoms of the third stage of hip-disease, which was of nineteen months’ duration. The abscess had 
advanced so far that a spontaneous opening occurred on the same day in which the patient was first 
examined, and before treatment could be instituted. The child’s general condition was bad. The limb 
was strongly flexed and adducted. The slightest attempts at motion elicited screams of pain. Exsection 
had already been urged by a medical attendant. 

Mechanical treatment was begun the sixth day after the patient was first examined. The appa- 
ratus used was the long hip-splint, first described by Dr. C. Fayette Taylor in 1867. Its essential parts 
are a pelvic band carrying two perineal straps which are applied to the ischiatic and pubic regions of 
the pelvis, for counter-extension, and a strong upright containing a sliding bar moved by a rack and 
pinion and having a rectangular piece extending under the sole of the foot. Adhesive plasters are 
attached to the limb and buckled to the foot-piece of the splint to ensure extension. A piece of 
webbing was buckled round the splint and the lower part of the thigh, although it is believed that the 
fixation power of the apparatus is increased by the substitution for this webbing, of a U-shaped piece 
of steel which retains the femur more nearly in a line parallel with the upright of the splint. This 
apparatus was used with a two-fold object; first, to afford a reasonable degree of immobility to the 
joint, and, secondly, to facilitate locomotion by acting as an ischiatic crutch. With the addition of an 
elevated shoe to the foot of the unaffected limb, the patient was about the house daily from almost the 
very beginning of treatment, and the affected limb was as free from concussion in locomotion as if it had 
been a naturally pendent member, calling to mind the words of the entertaining writer, M. Hennequin : 
“ Mais le corps humain pent il conserver pendant des mois entiers 1’ attitude verticale, touchant le sol 
par un pied seulement ? Evidemment non, cest au-dessus de ses forces. L’avenir nous reserve sans 
doute de grandes surprises, et ce qui est impossible aujourd’hui deviendra peut etre facile demain.” 
(Archives generates de medecine, Jan. 1869, p. 64.) 

[ 45 1 


The first application of a splint to a patient in the third stage of hip-disease is a matter of some 
difficulty. The apparatus is constructed as if it were to be applied to a symmetrical figure ; hence when 
first brought near the patient the symmetry of the splint throws the deformity into such marked relief 
as to make it seem impossible to use the apparatus. The free ends of the pelvic band may extend 
obliquely upwards over the thorax in front and behind, on account of the extreme adduction. The 
perineal straps may be far from occupying the places which they would fill if the patient’s body were 
symmetrical, indeed, it may be impossible at first to use them on the affected side. But with care and 
gentleness the instrument can be so arranged as to permit of a slight amount of extension and counter- 
extension. This is attended inevitably by a partial but most grateful arrest of motion and is followed 
immediately by a gradual reduction of the deformity. In 
a few days the symmetry of the patient’s figure will be so 
far restored that the splint is properly and comfortably 
worn. The pelvic band can then be lowered to its place 
below the level of the anterior superior spine of the ilium, 
the perineal straps will adapt themselves to the ischiatic 
and pubic regions, the flexion, of the femur will be 
materially diminished, and the adduction will have given 
place to abduction. This new abduction, with the 
consequent apparent lengthening, may become so great 
as to cause anxiety for the ultimate position of the 

Fig. 39. 

Fig. 38. 

limb. This, however, disappears in time. As the patient gathers strength from the absence of pain 
and the return of sleep and appetite, locomotion without crutches will be resumed, and it will be seen 
that the fixation afforded by the splint is so well adapted to the requirements of the case as to obviate 
pain and promote the reparative processes and yet not so firm as to prevent the gradual disappearance 
of the abduction and the further diminution of the flexion in obedience to the unconscious efforts of 
the patient to put the limb in the most favorable position for locomotion. These views of the action 
of the hip-splint in the reduction of the deformity of acute hip-disease are at variance with much that 
has been written on this subject, but they are founded on clinical observation. 

The changes from adduction to abduction and finally to a symmetrical position of the limb were 
observed in due order in this case. With the hip-joint thus protected from undue motion and also from 

r 46 


pressure and concussion, the patient was enabled to pursue the ordinary occupations of a boy of his 
age while the reparative process gradually supplanted the ravages of the disease Recovery, however, 
was not immediate. The abscess already referred to was followed at irregular intervals by other puru- 
lent collections which were incised or opened spontaneously until nine sinuses were established about 
the joint, all leading to carious bone. Five of these sinuses extended in a line down the outer side of the 
thigh from the trochanter to near the middle of the shaft of the femur, as seen in the cut, Fig. 37. The 
position and arrangement of these sinuses from one of which a fragment of cancellated bone was extended, 
the nature of the discharge, which was frequently offensive, and the character of the resulting cicatrices 
show that this was a case in which the shaft of the femur was to a considerable extent involved in the 
destructive osteitis. Although the progress of the case was generally towards recovery, there were 
stages in which the general condition of the patient was seriously affected. On such occasions the 
appetite failed, the tongue became coated, lassitude and irritability supervened and frequent ephemerae 
indicated how profoundly the system was affected by the local disturbance. At such times and more 
especially throughout the early and more critical period of the disease, cod-liver oil and other roborants 
were freely prescribed. The fact that the patient was enabled to move about and to amuse himself in 
the open air and sunshine was believed to be especially useful in supporting his general health and thus 
indirectly promoting the recovery of the involved joint. 

When the improvement in his general condition, the tolerance of motion in the joint and the 
disposition of the sinuses to close indicated the propriety of gradually relaxing the treatment, the splint 
was worn for some time with only a slight amount of traction, and finally the adhesive plasters were 
removed and the splint was worn for several months suspended merely by webbing passing over the 
shoulders, making, in fact, an ischiatic crutch. An elevated shoe on the foot of the unaffected side 
enabled him to walk briskly and at the same time to regain whatever motion could be got from a joint so 
thoroughly disorganized without exposing the new tissues to the violent concussion inseparable from 
ordinary locomotion. 

The patient was under treatment two years and five montths. His present condition, six 
months after treatment, is shown in the wood-cuts, Figs. 37 and 38. It is extremely favorable in view 
of the extensive destruction which had occurred in the joint, and the prolonged strain to which his 
system has been subjected by the disease. The limb is in good position, neither abducted nor adducted, 
and flexed at a slight angle, sufficient to allow him to sit comfortably, and yet not enough to interfere 
with locomotion. The motions of the knee are perfect. He walks with firmness, runs rapidly, and 
never uses a cane. The limp which accompanies rapid motion, and is slightly perceptible when 
he moves slowly, is partly the result of an inch of shortening and partly due to the absence of motion 
in the joint, lliat shortening comes not so much from the loss of bone at the upper extremity of the 
femur, as from a disparity in the size of the bony structures of the two legs, is illustrated in the 
outlines of the feet, Fig. 39, a disparity arising not only from disease and desuetude of the affected 
limb, but also, perhaps, from over-use of the unaffected limb. The remarkable locomotive power 
possessed by the patient in view of the size and importance of the joint affected, illustrates the ease 
with which motion is transferred from an impaired joint to the lumbar region of the spinal column and 
the hip-joint of the unaffected side. The auxiliary motion of these parts acquired thus in youth may 

[ 47 ] 


be expected to increase with t lie further growth of the patient. The position of the sinuses is shown 
in the figures. The cicatrices are firm, deeply depressed, and in some instances attached to the bone 
beneath. They are numbered in the order in which the sinuses made their appearance. The family 
history of this case shows no evidence of scrofula. 

Case II. — Was that of a girl, three years of age, whose mother died of consumption while the 
child was under my care. The family history showed that not only the mother, but also the maternal 
grandmother and three paternal uncles and aunts had died of phthisis pulmonalis. The disease was 
in the right hip, and had existed at least one year. Previous mechanical treatment had been by an 
immovable dressing of plaster of Paris, and afterwards by the use of a long hip-splint furnished 
with a single perineal strap, and applied without adhesive 
plasters. This splint was constructed with a joint at the 
level of the knee, for the purpose of assisting locomotion, 
which was further facilitated by the use of Darrach's wheel 
crutch. When first seen the child presented the marked 
adduction and flexion of the thigh characteristic of the 
third stage, and had suffered for several weeks the 
intense pain which is usually the forerunner of abscesses 
communicating with the joint. The treatment adopted 
was identical with that of Case I. Under its use the 
pain abated, and the position of the limb improved, 

Fig. 40. 

Fig. 42. 

Fig. 41. 

adduction giving place to abduction, and the flexion being materially diminished. But the abscess 
was not prevented. Five months after beginning treatment it was opened, and the sinus thus 
established on the outer surface of the thigh was followed, in the ensuing eighteen months, by five 
others, variously placed about the joint, which secreted an abundant and offensive pus, evidently from 
carious bone. The hip and upper part of the thigh were enormously swollen. During this period 
the treatment aimed at protecting the joint from motion and concussion and at fortifying the system 
so that Nature might check the destructive process, and substitute healthy or cicatricial tissue for that 
which was disintegrated. The treatment by tonics and roborants, viz., cod-liver oil, the more nutritive 
wines, chalybeates, &c., was apparently very much assisted by the use of a splint which allowed of 
locomotion in the erect position. With the exceptions to be mentioned, the patient, throughout 

[ 48 ] 


the entire treatment, was out of doors every day, walking with the aid solely of the ischiatic support 
furnished by the perineal straps of the hip-splint. There were occasions when, for several days 
together, it was impossible for the child to take her customary exercise on account of pain. At such 
times febrile reaction and emaciation threatened a fatal termination of the case by exhaustion, and 
these periods coincided with the development of new abscesses and sinuses. The most serious and 
prolonged relapse occurred when, from the death of the patient’s mother, it became necessary, for 
a time, to entrust the mechanical treatment to the child’s friends. Notwithstanding these complica- 
tions, the discharge slowly diminished, the sinuses gradually closed, some degree of motion was restored 
in the joint, and the re-establishment of the patient’s health showed that recovery was assured. 
Mechanical treatment was continued for two years and seven months. During the first half of that 
time strong traction was \ised, but during the latter half of the time, when it became apparent that 
fixation by the splint was no longer required, the apparatus was applied more loosely, and for several 
months it was worn only in the daytime, as an ischiatic crutch, to protect the new tissues of the 
affected part from pressure in standing, and concussion in locomotion. 

The patient’s present condition, eight months after the final removal of the splint, is well shown 
in the cuts, Figs. 40 and 41. The cicatrices are numbered in the order in which the sinuses appeared. 
Nos. 4 and 5 are attached to bone. The other scars are deeply depressed and attached to the fasciae. 
Her health is perfect and she is able to walk and run without assistance of any kind. The position of 
the femur is favorable both for walking and sitting, there being no abduction or adduction, but a mod- 
erate degree of flexion, and the shortening is only one-fourth of an inch, evidently due to a diminution 
in all the measurements of the limb. The outlines of the feet are seen in Fig. 42. When she walks 
slowly it is difficult to perceive any limping, although the motions of the joint itself are so slight as to 
be of very little, if any advantage in locomotion. Fast walking and running develop a slight limp, but 
not enough to prevent her from participating in all the pastimes of her time of life. 

Case III. — The family history of this case is remarkably free from evidences of scrofula. 
This boy, when first examined, was seven years old and had suffered from disease of the right hip for 
four years. The patient’s father, a surgical instrument maker, possessed unusual skill in the adaptation of 
apparatus, and hence the mechanical part of the treatment had not been neglected. The boy was provided 
with a long hip-splint which would have been serviceable had it not been constructed of such light 
materials that even a moderate degree of traction at the joint was impossible. At every step the 
instrument allowed the weight of the body to rest on the diseased joint. The usual signs of the third 
stage of hip-disease were present. Several weeks of severe pain had indicated the formation of an 
abscess, already recognizable by swelling, redness and heat on the inner surface of the thigh. Mechan- 
ical treatment was resorted to as soon as practicable in the same manner as in case I., which produced 
some relief from pain and a general improvement in the position of the limb. Suppuration progressed, 
however, until the hip and the upper part of the thigh were greatly distended and the pus was evacu- 
ated by incision or spontaneously, when four sinuses were established in the positions and in the order 
indicated in the cuts, Figs. 43 and 44, which presented the tumid and everted edges characteristic of 
sinuses leading to dead bone. The severity and persistence of the symptoms, the number and positions 
of the sinuses, the long continuance and often offensive nature of the discharge, and the character of 

[ 49 ] 


the resulting cicatrices, of which Nos. 2 ami 4 arc attached to bone, clearly show that the case was one 
of destructive ostitis and disorganization of the joint. For many weeks the constitutional disturbance 
was severe. There was pallor with frequent hectic flushes and elevation of the temperature. Exacer- 
bations of pain were partially relieved by the application of moist or dry heat. The diet was liberal 
and unrestricted in variety. Cod-liver oil and the ferruginous tonics were freely used. Notwithstanding 
the severity of the local symptoms and emaciation, the patient was usually able to be about the house, 
or out of doors, with the assistance of a pair of crutches, although it is probable that if he had not 
been previously dependent on them for a long time, he would have preferred to rely simply on the 
ischiatic support furnished by the splint. The slightest 
attempt at motion in the joint was exquisitely painful, 
and the patient, soon after the beginning of treatment, 
perceived that locomotion and even movement of the 
body in bed were painless only when extension and 
counter-extension, with a reasonable degree of im- 
mobility, were enforced. At the end of a year it 
became evident from the diminution of the purulent 
discharge, the disposition of the sinuses to close, the tol- 
erance of motion in the joint, and the improved con- 
dition of the patient that reparation was fairly estab- 
lished, and that fixation of the joint was no longer 
necessary. The splint was therefore removed and its 

Fig. 45. 

Fig. 44. 

place was supplied by an instrument which, receiving the patient’s weight on a single perineal strap, 
prevented his heel from reaching the ground and at the same time allowed of motion at the hip and 
knee. The crutches were then laid aside and this instrument was worn for three years, a longer time 
than was necessary, through excess of caution on the part of the patient’s father, who assumed the 
subsequent care of the case. 

The patient’s present condition, eighteen mouths after all treatment was discontinued, is well 
depicted in Figs. 43 and 44. lie is an active and robust school-boy, entering heartily into all the 
ordinary pursuits of a boy of his age. He takes long walks to and from school, and is a good skater. 

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When walking slowly there is no perceptible defect in gait. The limp which is developed in rapid 
movement does not prevent him from walking and running with great speed. lie never uses a cane. 
There is half an inch shortening. The position of the limb is good, there being a moderate degree of 
flexion, enough to facilitate sitting, but not sufficient to interfere with locomotion. There is neither 
abduction nor adduction of the femur. Motion at the joint is practically abolished, so that his remark- 
able power of locomotion is due to vicarious mobility of the lumbar region of the spine, and the 
unaffected hip-joint. The dimensions of the affected limb fall below those of its fellow, as is seen 
by the outlines of the feet (Fig. 45), and in the fact that there is a difference of one-fourth of an inch 
in the transverse measurements of the patellae. 

In reviewing these cases it is evident that the favorable results cannot be attributed to the 
superficial or trivial character of the lesions. They were cases in which the principal indications for 
exsection were present. In one of them exsection was advised by one whose name is prominent in the 
history of this operation. Dr. Oheever, in the midst of the performance of what has been termed 
“the majestic and sanguinary hip-joint operation” (Medical and Surgical Reporter, Philadelphia, June 
18, 1864, p. 383), remarked: “In this, as in every similar case, when you get into the joint you are 
surprised to see the amount of disease which did not appear externally” (Boston Medical and Surgical 
Journal, Aug. 22, 1878, p. 234). It may be inferred, therefore, that in the cases related, in which the 
external signs of disease lacked no element of severity, the lesions were destructive, invading the hard 
and soft parts of the joint, and were sufficiently serious to justify and even demand a resort to the most 
heroic measures. Operative procedure, however, gave place to mechanical treatment in accordance 
with views of pathology which may be stated briefly in these terms : the affection is not malignant, 
and is not seated in a vital organ. Sir Benjamin Brodie exclaimed: “Why should the disease be 
dangerous? The hip-joint is not a vital organ” (Clinical Lectures on Surgery, 1846, pp. 279, 280). 
Its activity depends largely on the motion of the part, and the pressure and concussion incident to its 
use in locomotion. This view and a reliance on the reparative power of Nature determined the adop- 
tion of a plan of treatment described above, which secured relief from acute pain, and which was 
followed not only by recovery, but by a degree of usefulness in the affected limb far beyond the usual 
results of exsection. 

It has been claimed that exsection relieves the patient at once from the pain of progressive hip 
disease in the third stage. Mr. Hancock, in his elaborate argument for exsection, draws the following- 
picture of a case of hip disease : “ Look at a patient wasted to a shadow, confined to his bed, not for 
months only, but for five years, in constant pain and in the last stage of exhaustion from long-continued 
discharge, his hands employed night and day incessantly maintaining a fixed position of the limb, and 
endeavoring to prevent the intense agony which occurs on the slightest movement. Often have I seen 
the poor liip-joint patient, when all others have slept, still wakeful and anxiously engrossed with the 
one and monotonous task of steadying the knee and preventing movement. Look again at this patient 
when the operation is performed ; his position now is no longer one of constraint and torture, it is one 
of comparative comfort and rest. He no longer suffers the extreme pain, he no longer exists in dread 
of the slightest movement or jar, his countenance loses its drawn and anxious appearance, the hectic 
subsides, and whatever may be the ultimate result, we at all events have the satisfaction of feeling that 
by the operation we have alleviated a very vast amount of suffering, almost beyond the power of 

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endurance ” (Lancet, June 1, 1872, p. 620). Great as is the relief thus depicted, it is not more marked 
than that which attends mechanical treatment in this stage of the disease. When fixation is secured, 
the anxious look gives way to an expression of repose, appetite and sleep return, and the reparative 
process begins. 

As Mr. Hancock has suggested, the question of recovery after exsection is a momentous one. 
It is a serious question even when the operation is performed under the most favorable circumstances, 
such as surrounded the patients of Mr. Annaudale. He was accustomed to operate at a very early 
stage of the disease. In one of his cases, a girl of sixteen years, the duration of the disease, previous 
to the operation, is recorded as three weeks. In the twenty-two cases which he reported in 1876, there 
were only five in which external sinuses existed. It will be seen from these facts that his cases were 
exceptionally favorable for operation, because they had not been weakened by exhausting discharges 
and long periods of suffering. Yet in these twenty-two cases death occurred in eight, at periods 
ranging from three to eighteen months after the operation (Edinburgh Medical Journal, February, 
1S76, p. 694). 

As hip disease derives its desperate character (its quasi malignancy) from the difficulty 
experienced in securing rest, and not from the nature of the disease, which is sufficiently amenable to 
treatment when occurring in other parts of the body, it follows that the rate of mortality is diminished 
by providing efficient rest and avoiding the risks of operation. 

Finally, in regard to the usefulness of the limb, the firm attitude shown in the figures,* the 
facility in walking and running possessed by the patients, and their ability to endure fatigue, leave but 
little to be desired for the results of treatment. 

The figures are from photographs in the library of the New York Hospital. 

[ 52 ] 

artqtype, e qierstaot n r 



Late House Surgeon Bellevue Hospital. 

Case. — Ellen Collins, ®t. thirty-seven; Irish; married; was admitted to Bellevue Hospital, 
October, 1871, for a burn from kerosene oil. After five months’ treatment the wound assumed the 
appearance seen in the illustration. It involved the whole right breast and arm, with a portion of the 
left breast ; and had ceased to cicatrize. The nipple had been renewed and the wound of the left breast 
almost covered by grafts from her own person and those of her friends. 

On March 10, 1872, I immersed an amputated leg in hot water and began grafting from it 
within three minutes after immersion. Thirty grafts were applied on the right side and covering a 
vertical space five by four and a-half inches, and almost all succeeded. 

March 23. — Being unable to take the amputated limb immediately to my patient, I wrapped 
it in flannel and placed it behind a coil of steam pipes ; beginning grafting one hour and thirty-five 
minutes after the operation. About one hundred grafts were applied, and on April 1, I counted 
eiglity-nine successful ones. 

On April 10, this photograph was taken to show the grafts of March 23. Another, taken 
three months later, showed the breast nearly healed, and the arm much improved. An acute pleurisy 
with effusion of the left side then set in and caused her death, on June 22, when everything 
promised success. A post-mortem showed that death was not directly due to the burn. She had 
received in all over 1500 grafts' in less than a year ; a large proportion of which were successful. 

1. History . — The history of skin-grafting is not a long one. In 1817, Professor Frank Hamil- 
ton, of New York City, suggested transplanting pedunculated flaps of skin to heal large wounds ; and 
applied this method in 1851.* But to Mons. Reverdin, of France, belongs the credit of first using 
detached grafts of skin. The successful transplantations were made October 16, 1S69 ; and his paper 
on “ Epidermic Grafting” was read before the Societe de Chirurgie de Paris, in December, 1869. f 

In May, 1870, Mr. George Pollock, of St. George’s Hospital, London, began grafting in 
England.:}: About the same time, Mr. D. Fides, of Aberdeen, Scotland, employed epidermic scrapings 

* N. Y. Med. Gazette, Aug. 20, 1870. 

t See Bulletin of same Society for 1869. Also Gaz. des hopitaux, Jan. 11 and 22, 1870. 

I For his cases and remarks see Transactions Clin. Soc. 1871. 

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